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

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

State/Territory: __________________Wyoming__________________________________________ (Name of State/Territory)

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

_________________________________________/s/___________________________________ ___ Brent D. Sherard, M.D., M.P.H., Director and State Health Officer Wyoming Department of Health

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

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Patricia Guzman Position/Title: CHIP Director Name: Kellie Grady Position/Title: Deputy CHIP Director Name: Position/Title:

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

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

Original State Plan:

Effective Date:

4/1/99

Implementation Date: 12/1/99

Amendment #1:

Effective Date:

June 13, 2001

Implementation Date: Not implemented

Amendment #2:

Effective Date:

July 1, 2002

Implementation Date: July 1, 2002

Amendment #3:

Effective Date:

July 1, 2003

Implementation Date: July 1, 2003

Amendment #4:

Effective Date:

July 1, 2005

Implementation Date: July 1, 2005

Amendment #5:

Effective Date:

July 1, 2007

Implementation Date: July 1, 2007

Amendment #6:

Effective Date:

October 1, 2009

Implementation Date: October 1, 2009

Amendment #7 Mental Health Parity, Medically Necessary Orthodontia & Medically Necessary & Dental Services

Effective Date: July 1, 2010

Implementation Date: July 1, 2010

Prospective Payment System to FQHC’s and RHC’s Effective date: October 1, 2009 Implementation date: September 1, 2010

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

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

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

The Department of Health, Children’s Health Insurance Program Office has primary responsibility for the operation of Kid Care CHIP. Wyoming has very little to no managed care in the state. Because of this Wyoming will rely primarily on one insurance plan for coverage under Kid Care CHIP.

An RFP is issued to private health insurance carriers every two to three years. Carriers are asked to propose plans that provide the required basic level of benefits that was set by Wyoming state statute and the Health Benefits Committee. A contract is awarded to one insurance company that in its proposal best addresses: price, level of benefits, provider network, outreach efforts, cost sharing, marketing, member rights, access to care, grievance procedures and continuation of a private pay basis if the family ceases to be eligible for CHIP.

Financing for Kid Care CHIP will be through Federal CHIP allotments matched by State General Funds.

Kid Care CHIP will follow the process described in the State Health Official letter (Page 3 – Supplemental Payments to FQHC and RHC Managed Care Subcontractors) to pay the supplemental payments to these organizations. Kid Care CHIP will be implementing an APM as part of this PPS requirement utilizing the Medicaid PPS rates that are already established in the state.

The supplemental payment amount will be calculated as follows:

• Our Contractor will pay their regular negotiated rate for each claim (so if they normally pay $85 for an office visit then they will pay $85). The Health plan will reimburse less than the APM and the supplement will pay up to PPS

• Then, each quarter, the contractor will run a report for Kid Care CHIP that shows every claim for each FQHC and RHC in the state and what they paid.

• Kid Care CHIP will then take the Medicaid PPS rate that is already established and compare that to the rate that contractor paid.

• Kid Care CHIP will then calculate what is owed based on the difference between what is paid by the contractor and what the PPS rate is. (If the contractor paid $85 to an FQHC and the PPS rate is $210.00, then Kid Care CHIP will pay $125.55 difference)

• Kid Care CHIP will then pay the FQHC or RHC a lump sum payment every four months to make up this difference of all claims paid by the contractor in the last quarter.

The FQHC’s and RHC’s have been sent information and agreements to sign. They are due back by August 16, 2010. We have been in contact with them and have not heard of any disagreements to date.

State funding will come from State General Funds. The General Funds appropriated for the PPS payment system are funds that are specifically allocated to the Department of Health, Kid Care CHIP program.

Kid Care CHIP will be implementing this process with payments effective in September 2010. This change is being made as the system to make the payments will not be ready on July 1, 2010 as originally expected.

6.2.10.

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

First Level of Benefits: Services furnished in a hospital, including a state- operated mental hospital; a residential or other 24-hour therapeutically planned structural service; or a partial hospitalization program are covered. Twenty-one days of inpatient mental health benefits are covered per benefit year. Partial hospitalization benefits may be exchanged for inpatient days at a rate of one inpatient day for two partial treatment days. A partial hospitalization program that is operated by a hospital shall comply with the standards for a partial hospitalization program that are published by the American Association for Partial Hospitalization.

The following specific limitations apply to coverage depending upon the child’s diagnosis and the treatment setting. A child who has applied for or been found eligible for Kid Care CHIP prior to becoming a patient in an IMD will be covered by Kid Care CHIP within the individual benefit limits specified in this section. However, a child who is a patient in an institution for mental disease who did not apply for Kid Care CHIP prior to admission is not eligible for Kid Care CHIP until he or she is discharged from the IMD.

No limits to inpatient mental health shall be imposed on children diagnosed with the following disorders as defined by the American Psychiatric Association: Schizophrenia, schizoaffective disorder, bipolar disorder, major depression, panic disorder, obsessive-compulsive disorder, autism.

Second Level of Benefits:

The second level of benefits provides for an additional nine (9) days of care, for a total of thirty (30) days per benefit year, with pre-approval and case management by the Insurance Company. The insurance Company will work closely with the provider to ensure treatment plans are in place and managed.

Mental Health or substance abuse disorders diagnosed will be covered. Mental Health or substance abuse benefits will be provided in parity with meidcal/surgical benefits to the extent provided in the following categories: inpatient, outpatient, in-network, out of network, emergency and prescription drugs.

6.2.11.

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

First Level of Benefits: Professional outpatient mental health services up to a maximum of twenty visits per year are covered. The visits can be furnished in a variety of community based settings or in a mental hospital. Partial hospitalization benefits are paid as described in the inpatient mental health benefits section.

No limits to outpatient mental health benefits shall be imposed on children diagnosed with the following disorders as defined by the American Psychiatric Assoc: Schizophrenia, schizoaffective disorder, bipolar disorder, major depression, panic disorder, obsessive-compulsive disorder, autism.

Second Level of Benefits:

The second level of benefits provides for an additional twenty (20) outpatient visits per benefit year, for a total of forty (40) days per benefit year, with pre- approval and case management by the insurance Company. The insurance company will work closely with the provider to ensure treatment plans are in place and managed. Providers will have the capability to bill for partial (30 minutes or less) and full (more than 30 minutes) sessions. This capability only applies to the second level of benefits.

Mental Health or substance abuse disorders diagnosed will be covered. Mental Health or substance abuse benefits will be provided in parity with meidcal/surgical benefits to the extent provided in the following categories: inpatient, outpatient, in-network, out of network, emergency and prescription drugs.

6.2.17. Dental services (Section 2110(a)(17))

Kid Care CHIP will provide a State Defined Dental Benefit Package. This package will include requirements from section 2103(c)(5) of CHIPRA, including “coverage of dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.” Benefits include: Exams, cleanings, bitewing x-rays, fluoride treatments, sealants, full mouth x-rays, space maintainers, fillings, simple extractions, gold or porcelain crowns for teenagers with adult or permanent dentition, full mouth debridement for teenagers with permanent dentition, partials for teenagers with permanent dentition and missing anterior teeth, sedation for younger children, emergency treatment for the relief of pain, medically necessary dental services and medically necessary orthodontics. Annual maximum is $1,000 per benefit year. Preventive and diagnostic services (Exams, cleanings, fluoride, space maintainers, sealants and x-rays) are subject only to frequency limitations and are not included in the child’s yearly benefit maximum. Medically necessary dental services will be covered even if a child has reached their $1,000 annual maximum benefit.

6.2.18.

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

The combined benefit for inpatient and outpatient treatment for alcoholism and drug addiction, excluding costs for medical detoxification, is subject to a maximum benefit of $6,000 in a 12-month period, until a lifetime inpatient maximum benefit of $12,000 is met, after which the annual benefit may be reduced to $2,000. Costs for medical detoxification treatment must be paid the same as any other illness under the terms of the contract and are not subject to the lifetime limits.

Mental Health or substance abuse disorders diagnosed will be covered. Mental Health or substance abuse benefits will be provided in parity with meidcal/surgical benefits to the extent provided in the following categories: inpatient, outpatient, in-network, out of network, emergency and prescription drugs.

6.2.19.

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

The combined benefit for inpatient and outpatient treatment for alcoholism and drug addiction, excluding costs for medical detoxification, is subject to a maximum benefit of $6,000 in a 12 month period until a lifetime maximum inpatient benefit of $12,000 is met, after which the annual benefit may be reduced to $2,000. Costs for medical detoxification treatment must be paid the same as any other illness under the terms of the contract and are not subject to the lifetime limits.

Mental Health or substance abuse disorders diagnosed will be covered. Mental Health or substance abuse benefits will be provided in parity with meidcal/surgical benefits to the extent provided in the following categories: inpatient, outpatient, in-network, out of network, emergency and prescription drugs.

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

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c))

There are three levels of cost sharing: Plan A for enrollees up to 100% of the federal poverty level & Native American Children; Plan B for enrollees 101% through 150% of the federal poverty level; and Plan C for enrollees 151% through 200% of the federal poverty level.

8.2.1. Premiums: No premiums will be charged to families. 8.2.2. Deductibles: No deductibles will be charged to families Coinsurance or copayments: Plan A: No Co-payments for Services

Plan B:

Benefits Co-payments Total Family Out of Pocket Maximum per Benefit Year

5% of the family’s gross yearly income** Medical and Vision Out of pocket maximum per benefit year

$200 per child

Office visits (including mental health) $5

Well Child Exams No-copayment required

Immunizations No co-payment required

Lab and X-ray No-co-payment required

Outpatient Hospital $5

Inpatient Hospital $30

Emergency Room $5 Pharmacy out of pocket maximum per benefit year

$100 per child

Generic prescriptions $3

Brand name prescriptions $5

Dental out of pocket maximum per benefit year

$15 per child $15 per child - orthodontics

Preventive and Diagnostic Services (exams, cleanings, No co-payment required

flouride, sealants)

Basic and Major Services (fillings, extractions, etc) $5 per visit

Medically Necessary Orthodontics $5 per visit **Kid Care CHIP will send families an approval letter telling them the out of pocket maximum amount for their family.

Plan C:

Benefits Co-payments Total Family Out of Pocket Maximum per Benefit Year

5% of the family’s gross yearly income** Medical and Vision Out of pocket maximum per benefit year

$300 per child

Office visits (including mental health) $10 per child

Well Child Exams No Co-payment Required

Immunizations No Co-payment Required

Lab and X-ray No Co-payment Required

Outpatient Hospital $10

Inpatient Hospital $50

Emergency Room $25 Pharmacy out of pocket maximum per benefit year

$200 per child

Generic prescriptions $5

Brand Name prescriptions $10

Dental out of pocket maximum per benefit year

$75 per child $75 per child - orthodontics

Preventive and Diagnostic Services (exams, cleanings, flouride, sealants) No co-payment required

Basic and Major Services (fillings, extractions, etc) $25 per visit

Medically Necessary Orthodontics $25 per visit

Kid Care CHIP mailed cost sharing updates to families on April 30, 2010 that outlined upcoming changes to the program. This document was also provided to provider offices and any other organization partnering with Kid Care CHIP to conduct outreach and enrollment activities. Revisions to our benefit books from both Blue Cross Blue Shield and Delta Dental of Wyoming were also mailed to families in June 2010. These revisions outline the upcoming changes to the benefits and cost sharing in Kid Care CHIP.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures Deleted: ¶

required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c))

As indicated in section 4.4.5 Kid Care CHIP works directly with the tribes, the Tribal Health Services and the Indian Health Service to inform Native Americans in Wyoming about Kid Care CHIP. The representatives of the tribes and organizations in the state have been in all state-wide partnerships and individual relationships have been made, which assures their input in the design of an effective outreach and marketing campaign for Kid Care CHIP that will be acceptable to the tribes.

Kid Care CHIP presented upcoming changes to Indian Health Services, Wind River Health Systems and other organizations on the reservation in May 2010.

Kid Care CHIP attempted to present to the Joint Tribal Councils, twice (once in May and once in June) but due to Tribal Council cancellations & recent flooding we were unable to present to them in person. We have contacted their offices but have not received any comments back from the Tribal Council on the documents we provided to them.

The meeting with Wind River Health Systems was attended by Indian Health Services, Tribal Council Members, Wind River Health Systems, Public Health, School officials, WIC and Head Start officials.

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

Public Notice for all cost sharing changes to Kid Care CHIP will be made according to State law. The public notice for the public meeting and rules will be published in Wyoming newspapers and the public meeting will be held within no less than thirty days prior to implementation. The published notice will advise of the changes being made to Kid Care CHIP cost sharing. As an additional step, the Department of Health will also address the cost sharing in the public notice for the administrative rule for Kid Care CHIP that will be issued prior to October 1, 2009. July 2010.

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

 Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and

- Assumptions on which the budget is based, including cost per child and expected enrollment.  Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

SCHIP Budget Plan Template Wyoming

Federal Fiscal Year 2010 2011 Costs Enhanced FMAP rate 65.00% Benefit Costs

Insurance payments

Managed care

per member/per month rate @ # of eligibles

FQHC & RHC Managed Care PPS payments Med. Necessary Ortho @ # of estimated eligibles $214.13 @ 5980 $223.50 @ 5505 $150,000 $168,750 Fee for Service

Total Benefit Costs $15,040,491 $14,764,410 $150,000 $168,750

(Offsetting beneficiary cost sharing payments) $0 Net Benefit Costs*** $15,040,491 $15,083,160

Administration Costs

Personnel $552,850 $526,532 General administration $ 72,669 Contractors/Brokers (e.g., enrollment contractors) $136,950 $96,000 Claims Processing Included in Premiums Outreach/marketing costs $53,417 $34,000 Other (Indirect/Rent) $132,818

Total Administration Costs $948,704 $862,019 10% Administrative Cost Ceiling $1,508,332

$1,508,316

Federal Share (multiplied by enh-FMAP rate) $10,392,977 $10,364,366 State Share $ 5,596,218 $5,580,813 TOTAL PROGRAM COSTS $15,989,195 $15,945,179 Note: The Federal Fiscal Year (FFY) runs from October 1st through September 30th.

Funding: State funding will come from one source: State General Funds.

***Net Benefit Costs are based on enrollment by month multiplied by the premium of $214.13 $223.50.

Below please find estimated enrollment for Kid Care CHIP by month * does not include FQHC/RHC PPS or Medically Necessary Orthodontia (10/10-9/11)

Month Enrollment Number Total Premium Federal State 10/10 5450 $1,218,075 $791,749 $426,326.25 11/10 5460 $1,220,310 $793,202 $427,108.50 12/10 5470 $1,222,545 $794,654 $427,890.75 1/11 5480 $1,224,780 $796,107 $428,673.00 2/11 5490 $1,227,015 $797,560 $429,455.25 3/11 5500 $1,229,250 $799,013 $430,237.50 4/11 5510 $1,231,485 $800,465 $431,019.75 5/11 5520 $1,233,720 $801,918 $431,802.00 6/12 5530 $1,235,955 $803,371 $432,584.25 7/12 5540 $1,238,190 $804,824 $433,366.50 8/12 5560 $1,242,660 $807,729 $434,931.00

PPS for FQHC’s and RHC’s: In the first two quarters of FFY 2010, the difference between the payments made by Blue Cross Blue Shield and Delta Dental of Wyoming and the PPS rates established by Wyoming Medicaid equaled approximately $75,000. Since this is the data we have to date we are utilizing this to make our estimates for the next year. $75,000 x 2 = $150,000 for one year. $150,000 x 2 = $300,000 for two years.

Medically Necessary Orthodontia: $3,750 maximum per child x 45 children (estimated) = $168,750 Deleted: TOTAL ...

Personnel Kid Care CHIP will have seven positions dedicated to administering the program.

Supportive Services General operations costs include equipment, travel, office supplies, and postage, printing, and telephone toll charges.

Case Services Estimated monthly premium is $214.13 $223.50 based on the programs most recent contract that was issued in 2009 2010. Contractual Services The services listed below will be contracted services:

Consultant services to conduct research and assist in the design and implementation of the eligibility system for Kid Care CHIP.

Legal fees for the development of administrative rules

Sources of Non-Federal Share of Expenditures In addition to federal funds, Kid Care CHIP State general fund appropriations will be used. Enrollment projections are based on current estimates of funds which will be appropriated for Kid Care CHIP. If enrollment expectations exceed those projected for funding, new enrollment may be suspended.

WYOMING TITLE XXI PROGRAM FACT SHEET

Name of Plan:

Wyoming Kid Care

Date Plan Submitted:

August 5, 1999 Date Plan Approved:

September 8, 1999 Effective Date:

April 1, 1999

Date Amendment #1 Submitted:

March 16, 2001 Date Amendment #1 Approved:

June 13, 2001 Date Amendment # 1 Effective:

September 1, 2001

Date Amendment #2 Submitted:

June 20, 2002 Date Amendment #2 Approved:

September 18, 2002

Date Amendment #3 Submitted:

April 1, 2003 Date Amendment #3 Approved:

June 30, 2003 Date Amendment #3 Effective:

July 1, 2003

Date Amendment #4 Submitted:

April 5, 2005 Date Amendment #4 Approved:

June 24, 2005 Date Amendment #4 Effective:

July 1, 2005

Date Amendment #5 Submitted: April 16, 2007 Date Amendment #5 Approved:

June 27, 2007 Date Amendment #5 Effective:

July 1, 2007

Date Amendment #6 Submitted:

May 18, 2009 Date Amendment #6 Approved:

September 8, 2009 Date Amendment #6 Effective:

October 1, 2009

Date Amendment # 7 Submitted: June 3, 2010 Date Amendment #7 Approved:

August 12, 2010 Date Amendment #7 Effective:

July 1, 2010

Background:

• On April 5, 1999, Wyoming submitted its initial SCHIP State plan to establish a separate child health program. The initial State plan provided coverage to children up to age 19 in families with family incomes up to 133 percent of the Federal poverty level (FPL), who are not eligible for Medicaid.

• Wyoming’s Medicaid program, EqualityCare, covers children through age 5 up to 133 percent of the FPL and children ages 6 through age 18 up to 100 percent of the FPL.

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• Wyoming’s approved program, Kid Care CHIP, extends coverage to children in families with incomes from 134 to 200 percent of the FPL. Kid Care CHIP offers children a Secretary-approved benefit package through a private insurance carrier.

Amendments

• Wyoming submitted its first amendment on March 6, 2001. This amendment established Kid Care C to provide coverage to children between 134 and 150 percent of the FPL through coverage obtained from eligible employers’ plans or from the private health insurance market. Kid Care C was never implemented.

• Wyoming submitted its second amendment on June 20, 2002. This amendment updates and amends the SCHIP State plan to indicate the State’s compliance with the final SCHIP regulation.

• Wyoming submitted its third amendment on April 1, 2003. This amendment extends coverage to children with family incomes from 134 to 185 percent of the FPL, amends the State’s Secretary-approved benefit package, replaces the current Medicaid look-alike benefit package with the amended Secretary-approved benefit package, and implements cost sharing.

• The State submitted its fourth amendment on April 5, 2005. Through this amendment, Wyoming expanded the upper eligibility limit from 185 percent of the FPL to 200 percent of the FPL. This amendment also added additional dental services and increased the annual maximums for dental services, physical and occupational therapy, and services for individuals with speech, hearing and language disorders.

• The State submitted its fifth amendment on April 16, 2007. Through this amendment, Wyoming expanded inpatient mental health benefits from the current twenty-one days per year of coverage to an additional nine days of care per year; changed the current dental benefits to exclude preventative and diagnostic services from the child’s yearly benefit maximum; added contact lenses to the current vision benefits and updated the State’s current strategic objectives, performance goals and performance measures.

• Wyoming submitted its sixth amendment on May 18, 2009. This amendment makes changes to the State’s cost sharing and enrollment procedures, including providing applicants with access to an online application and changing its process for implementing an enrollment cap under its existing State plan authority.

• Wyoming submitted its seventh amendment on June 3, 2010. This amendment complies with the Children’s Health Insurance Reauthorization Plan (CHIPRA) mandates for mental health parity and with requirements for medically necessary dental care and orthodontics. The SPA also proposes to meet the alternative payment methodology for FQHCs and RHCs by establishing a process that every four months, the State reviews the difference between the Blue Cross and Blue Shield current payment rate and what each

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FQHC or RHC would be paid through a prospective payment methodology. If the FQHC or RHC is paid less than they would be under a prospective payment methodology, then the State will pay each facility the difference. If the payment is higher than it would be under the prospective payment methodology, then the State will not seek to recapture that payment overage. The State is estimating that an additional aggregate $150,000 each year will be paid to the FQHCs and RHCs in the State. The source of these funds is the State’s General Fund.

Children Covered Under the Program

• The State reported that 8,871 children were ever enrolled in its program during Federal fiscal year 2009.

Administration

• The Community and Family Health Division of the Wyoming Department of Health (WDH), working closely with the Kid Care coalition, administers the State’s separate child health program, Kid Care CHIP.

Health Care Delivery System

• The delivery system through which both Medicaid and Kid Care CHIP operate is a contracted fee-for-service model. The penetration rate for managed care systems is low in Wyoming and there is no Medicaid managed care system or a primary care case management program.

• WDH contracts with one private insurance company to provide insurance coverage to Kid Care CHIP participants.

Benefit Package

• Benefits provided under Kid Care CHIP are through Secretary-approved coverage.

• The benefit package includes well-baby and well-child services, immunizations, emergency services, inpatient and outpatient care, prescription drugs, diagnostic services, dental services, medically necessary orthodontics, vision, and inpatient and outpatient mental health and substance abuse treatment and services.

Crowd-Out Strategy

• An applicant is ineligible for Kid Care CHIP if the applicant has voluntarily terminated their group health plan or individual coverage within the month prior to the application date for coverage.

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• If a parent who is providing the primary insurance is fired, laid off, can no longer work because of a disability, or has a lapse in insurance coverage because he/she obtains new employment, the child may be eligible for Kid Care CHIP.

Cost Sharing

• There are no premiums or deductibles but there are co-payments for services. There are three levels of cost sharing based on family income. Plan A for those with family income below 100 percent of the FPL; Plan B for those with family income between 101 and 150 percent of the FPL; and Plan C for families with incomes between 151 and 200 percent of the FPL. All cost-sharing is capped at 5 percent of income. o Plan A requires no copayments for services. o Under Plan B, there is a maximum of $200 per child annually for medical and vision out-of-pocket expenses per plan year. Individual copayments consist of $5 office visits, $5 outpatient hospital, $30 inpatient hospital and $5 emergency room charges. Plan B restricts copayments to $100 per child per plan year for pharmacy benefits at $3 for each generic prescription and $5 for a brand prescription. The dental out of pocket maximum a year is $15 per child. No copayment is required for preventive and diagnostic services while basic and major services require $5 per visit. o Under Plan C, there is a cap of 300 per child per plan year for medical and vision out-of-pocket. Copayment amounts are $10 per office visits, $10 copayment for outpatient hospital visits, $50 for inpatient hospital and $25 for emergency room visits. The pharmacy annual maximum is $200 per child comprised of $5 per generic prescription or $10 per brand name prescription. Dental out-of-pocket costs are capped at $75 per child per plan year with no copayment required for preventive and diagnostic services and $25 per visit required for basic and major services.

State Outreach and Enrollment Activities

• Kid Care CHIP will use an outreach and marketing campaign developed by the Kid Care CHIP program to inform families of children likely to be eligible for Kid Care CHIP or other public or private health coverage programs of the availability of these programs and to assist them in enrolling their children. It is also anticipated that insurance companies will conduct direct marketing efforts.

• The Kid Care CHIP program is continuing the Coalition that the Robert Wood Johnson Covering Kids and Families grant began. The “Covering Kids” Coalition includes representatives from child advocacy organizations, education organizations, health care provider associations, the insurance industry, and other public and private providers who are concerned with children’s health.

Coordination Between CHIP and Medicaid

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• All Kid Care Plans use a single eligibility application. The form contains the information necessary to determine eligibility for all Kid Care programs. The application is screened for EqualityCare (Medicaid) eligibility prior to determining eligibility for KidCare CHIP.

• Through SPA #6 the State implemented a new on-line application process to facilitate enrollment into the healthcare programs.

Financial Information

Total FFY ‘10 CHIP Allotment—$12,063,423 FFY ’10 Enhanced Federal Matching Rate—65%

Date Last Updated—August 17, 2010

_____________________________________________________________________________ Table of Contents State/Territory Name: Wyoming State Plan Amendments (SPA) #: WY-13-0012 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Wyoming consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services C Mi

7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850 cet cehb ci sues

Children and Adults Health Programs Group

MAR 2 6 2014

Ms. Susie Scott

CHIP Director & Kid Care CHIP Manager Wyoming Department of Health

6101 Yellowstone Rd, Suite 210 Cheyenne, WY 82002

Dear Ms. Scott:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number WY-13-0012 submitted on February 12, 2014, and related Modified Adjusted Gross Income (MAGI) Eligibility with an effective date of January 1, 2014.

The SPA number WY-13-0012 describes the state’s plan to provide coverage in its separate CHIP, for children subject to section 2101(f) of the Affordable Care Act, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved CS14 is attached, and should be incorporated within a separate subsection under section 4.1 of Wyoming’s approved CHIP state plan.

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

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

Official communications regarding program matter should be sent simultaneously to Ms. Jordan and to Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office. Mr. Allen’s address is:

Page 2 - Ms. Susie Scott Centers for Medicare & Medicaid Services Denver Regional Office Colorado State Bank Building 1600 Broadway, Suite# 700 Denver, CO 80202-4967 Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SP As. If you have additional questions, please contact Ms. Barbara K. Richards, Acting Director, Division of State Coverage Programs at (410) 786-5920. Enclosure cc: Sincerely, Eliot Fishman Director Richard Allen, ARA, CMS Region VIII, Denver / Eliot Fishman/

Children's Health Insurance Program Eligibility

Control Panel

General Information

File Management

Tribal Input

Summary

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Wyoming

name: Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number

with leading zeros. The dashes must also be entered. |wy-13-0012

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

(nm/ae/yyyy)

Federal Statute/ Regulation Citation

[2104(f) of the Affordable Care Act and 42 CFR 457.310(d)

Federal Budget Impact

This SPA has a budget impact. Total budget impact:

State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes.

Character Count: 608 out of 2000 (The amendment assures that CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of aA income disregards in accordance with 42 CFR 457.310(d). The amendment further clarifies that coverage for this population Vv will cease when the last child protected from loss of Medicaid

Signature of State Agency Official

Submitted By: Chris Bass

Last Revision Feb 20, 2014 Date: Submit Date: Feb 12, 2014

Ss CHIP Eligibility

IMEC 196 NUCL READ MINE

OMB Control Number: 0938-1148 : i 0/31/2014

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

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

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

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

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

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

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

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their first renewal applying MAGI methods.

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

% FPL,

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

C Other.

Describe the benefits provided to this population:

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

@ This population will be provided the same benefits as are provided to children in the state's separate CHIP,

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

Describe premiums and cost sharing required of this population:

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

SPA# WY-13-0012 Approval Date: MAR 2 6 2014 Effective Date: January 1, 2014 Page | of 2

CRAS CHIP Eligibility

ITER EOE ARDS ASETRENIE SERVICE

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

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

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

SPA# WY-13-0012 Approval Date: MAR 2 6 2014 Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Wyoming State Plan Amendments (SPA) #: WY-18-0013 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop $2-01-16 @ Y, | Ge, Baltimore, MD 21244-1850

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

Children and Adults Health Programs Group

MAR 1 2 2020

Christine Bates

Kid Care CHIP Manager Wyoming Department of Health Division of Healthcare Financing 6101 Yellowstone Road Suite 210 Cheyenne, WY 82002

Dear Ms. Bates:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA), WY- 18-0013, submitted on June 29, 2018, with additional information submitted on March 9, 2020, has been approved. Through this SPA, Wyoming implements mental health parity requirements to ensure that treatment limitations applied to mental health (MH) and substance use disorder (SUD) benefits are no more restrictive than those applied to medical/surgical (M/S) benefits. This SPA has an effective date of October 2, 2017.

Sections 2103(c)(7)(A) of the Social Security Act (the Act), as implemented through regulations at 42 CFR 457.496(d)(3)-(5), requires states that provide both M/S and MH/SUD benefits to ensure that financial requirements and treatment limitations applied to MH/SUD benefits covered under the state child health plan are consistent with the mental health parity requirements of section 2705(a) of the Public Health Service Act, in the same manner that such requirements apply to a group health plan. Wyoming demonstrated compliance by providing the necessary assurances and supporting documentation that the state’s application of non- quantitative treatment limitations and financial requirements to MH/SUD benefits are consistent with section 2103(c)(7)(A) of the Act.

In addition, Wyoming updated its member handbook to clarify its policies regarding the application of prior authorization to the physical, occupational, and speech therapy benefit, including being able to exceed the $750 annual limit if medically necessary.

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

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

Page 2 — Ms. Christine Bates

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

E-mail: Joyce.Jordan@cms.hhs.gov

If you have additional questions, please contact Meg Barry, Acting Director, Division of State Coverage Programs at (410) 786-1536.

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

/signed Amy Lutzky/

Amy Lutzky Acting Deputy Director

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

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

State/Territory: Wyoming (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR 457.40(b)) ____________________________________________________________________________________ Teri Green, State Medicaid Director (Signature of Governor, or designee, of State/Territory, Date Signed)

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

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

Name: Jan Stall

Position/Title: Eligibility and Operations Administrator Name: Christine Bates

Position/Title: Kid Care CHIP Manager

Name:

Position/Title:

*Disclosure. 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 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 105-33 amended

2 the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the program.

This template outlines the information that must be included in the state plans and the state plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: • Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. • Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) • Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. • Removed crowd-out language that had been added by the August 17 letter that later was repealed. The Centers for Medicare & Medicaid Services (CMS) is developing regulations to implement the CHIPRA requirements. When final regulations are published in the Federal Register, this template will be modified to reflect those rules and States will be required to submit SPAs illustrating compliance with the new regulations. States are not required to resubmit their State plans based on the updated template. However, States must use the updated template when submitting a State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

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

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires a description that must include both proposed methods of delivery and proposed utilization control systems. This section should fully describe the delivery system of the Title XXI program including the proposed contracting standards, the proposed delivery systems and the plans for enrolling providers. (Section 2103); (42 CFR 457.410(A)) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42 CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage;

4 benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary- approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre- existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

5

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: • Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. • Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State Plan Amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children’s Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections)

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State

6 may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

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

7 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)(1)); (42 CFR 457.70):

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

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

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

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

1.1-DS

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

1.2.

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

1.3.

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

8

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

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

Original Plan Effective Date: July 1, 2002

Implementation Date: July 1, 2002

SPA #WY-18-0013 Purpose of SPA: Demonstrate compliance with the Mental Health Parity and Addiction Equity Act of 2008. Proposed effective date: October 2, 2017

Proposed implementation date: October 2, 2017

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. Tribal notice was sent via email on June 28, 2018.

TN No: Approval Date Effective Date

9 6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i))

6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard.

International Classification of Disease (ICD) ICD-10-CM Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines (Describe: ) Other (Describe: ) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits?

Yes No Guidance: If the State does not provide any mental health or substance use disorder benefits, the mental health parity requirements do not apply ((42 CFR 457.496(f)(1)). Continue on to Section 6.3.

6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act) provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment

10 services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act.

6.2.2.1- MHPAEA Does the State child health plan provide coverage of EPSDT? The State must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements, as indicated in section 6.2.26 of the State child health plan in order to answer “yes.”

Yes No Guidance: If the State child health plan does not provide EPSDT consistent with Medicaid statutory requirements at sections 1902(a)(43) and 1905(r) of the Act, please go to Section 6.2.3- MHPAEA to complete the required parity analysis of the State child health plan.

If the state does provide EPSDT benefits consistent with Medicaid requirements, please continue this section to demonstrate compliance with the statutory requirements of section 2103(c)(6)(B) of the Act and the mental health parity regulations of 42 CFR 457.496(b) related to deemed compliance. Please provide supporting documentation, such as contract language, provider manuals, and/or member handbooks describing the state’s provision of EPSDT.

6.2.2.2- MHPAEA EPSDT benefits are provided to the following:

All children covered under the State child health plan. A subset of children covered under the State child health plan. Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements.

Guidance: If only a subset of children are provided EPSDT benefits under the State child health plan, 42 CFR 457.496(b)(3) limits deemed compliance to those children only and Section 6.2.3- MHPAEA must be completed as well as the required parity analysis for the other children.

6.2.2.3- MHPAEA To be deemed compliant with the MHPAEA parity requirements, States must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act (42 CFR

11 457.496(b)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan:

All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions. (Section 1905(r))

All diagnostic services described in 1905(a) of the Act are provided as needed to diagnose suspected conditions or illnesses discovered through screening services, whether or not those services are covered under the Medicaid state plan. (Section 1905(r))

All items and services described in section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan. (Section 1905(r)(5))

Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness. (Section 1905(r)(5))

Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness. (Section 1905(r)(5))

EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis. (Section 1905(r)(5))

The provision of all requested EPSDT screening services, as well as any corrective treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1902(a)(43))

12

All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A)) Guidance: For states seeking deemed compliance for their entire State child health plan population, please continue to Section 6.3. If not all of the covered populations are offered EPSDT, the State must conduct a parity analysis of the benefit packages provided to those populations. Please continue to 6.2.3- MHPAEA.

Mental Health Parity Analysis Requirements for States Not Providing EPSDT to All Covered Populations

Guidance: The State must complete a parity analysis for each population under the State child health plan that is not provided the EPSDT benefit consistent with the requirements 42 CFR 457.496(b). If the State provides benefits or limitations that vary within the child or pregnant woman populations, states should perform a parity analysis for each of the benefit packages. For example, if different financial requirements are applied according to a beneficiary’s income, a separate parity analysis is needed for the benefit package provided at each income level.

Please ensure that changes made to benefit limitations under the State child health plan as a result of the parity analysis are also made in Section 6.2.

6.2.3- MHPAEA In order to conduct the parity analysis, the State must place all medical/surgical and mental health and substance use disorder benefits covered under the State child health plan into one of four classifications: Inpatient, outpatient, emergency care, and prescription drugs. (42 CFR 457.496(d)(2)(ii); 42 CFR 457.496(d)(3)(ii)(B))

6.2.3.1 MHPAEA Please describe below the standard(s) used to place covered benefits into one of the four classifications.

The final regulations specify that requirements for FRs and treatment limitations apply by benefit classification. Kid Care CHIP benefits were classified and mapped into four categories, as directed by the CMS Parity Toolkit. The following definitions were used to determine benefit classifications: Inpatient: Treatment as a registered bed patient in a hospital or facility other provider and for whom a room and board charge is made. Outpatient: All covered services or supplies not included in inpatient, emergency care, or prescription drug categories.

13 Prescription Drugs: Medications that have been approved or regulated by the Food and Drug Administration that can, under federal and state law, be dispensed only pursuant to a Prescription Drug order from a licensed, certified, or otherwise legally authorized prescriber. Emergency Care: All covered emergency services or items (including medications) provided in an emergency department (ED) or emergency room (ER) setting in an OP hospital setting. 6.2.3.1.1 MHPAEA The State assures that:

The State has classified all benefits covered under the State plan into one of the four classifications. The same reasonable standards are used for determining the classification for a mental health or substance use disorder benefit as are used for determining the classification of medical/surgical benefits. 6.2.3.1.2- MHPAEA Does the State use sub-classifications to distinguish between office visits and other outpatient services?

Yes No

6.2.3.1.2.1- MHPAEA If the State uses sub-classifications to distinguish between outpatient office visits and other outpatient services, the State assures the following:

The sub-classifications are only used to distinguish office visits from other outpatient items and services, and are not used to distinguish between similar services on other bases (ex: generalist vs. specialist visits). Guidance: For purposes of this section, any reference to “classification(s)” includes sub-classification(s) in states using sub- classifications to distinguish between outpatient office visits from other outpatient services.

6.2.3.2 MHPAEA The State assures that:

Mental health/ substance use disorder benefits are provided in all classifications in which medical/surgical benefits are provided under the State child health plan.

14 Guidance: States are not required to cover mental health or substance use disorder benefits (42 CFR 457.496(f)(2)). However if a state does provide any mental health or substance use disorder benefits, those mental health or substance use disorder benefits must be provided in all the same classifications in which medical/surgical benefits are covered under the State child health plan (42 CFR 457.496(d)(2)(ii).

Annual and Aggregate Lifetime Dollar Limits

6.2.4- MHPAEA A State that provides both medical/surgical benefits and mental health and/or substance use disorder benefits must comply with parity requirements related to annual and aggregate lifetime dollar limits for benefits covered under the State child health plan. (42 CFR 457.496(c))

6.2.4.1- MHPAEA Please indicate whether the State applies an aggregate lifetime dollar limit and/or an annual dollar limit on any mental health or substance abuse disorder benefits covered under the State child health plan.

Aggregate lifetime dollar limit is applied Aggregate annual dollar limit is applied No dollar limit is applied Guidance: A monetary coverage limit that applies to all CHIP services provided under the State child health plan is not subject to parity requirements.

If there are no aggregate lifetime or annual dollar limits on any mental health or substance use disorder benefits, please go to section 6.2.5- MHPAEA.

6.2.4.2- MHPAEA Are there any medical/surgical benefits covered under the State child health plan that have either an aggregate lifetime dollar limit or an annual dollar limit? If yes, please specify what type of limits apply.

Yes (Type(s) of limit: No Guidance: If no aggregate lifetime dollar limit is applied to medical/ surgical benefits, the State may not impose an aggregate lifetime dollar limit on any mental health or substance use disorder benefits. If no aggregate annual dollar limit is applied to medical/surgical benefits, the State may not impose an aggregate annual dollar limit on any mental health or substance use disorder benefits. (42 CFR 457.496(c)(1))

15

6.2.4.3 – MHPAEA. States applying an aggregate lifetime or annual dollar limit on medical/surgical benefits and mental health or substance use disorder benefits must determine whether the portion of the medical/surgical benefits to which the limit applies is less than one- third, at least one-third but less than two-thirds, or at least two-thirds of all medical/surgical benefits covered under the State plan (42 CFR 457.496(c)). The portion of medical/surgical benefits subject to the limit is based on the dollar amount expected to be paid for all medical/surgical benefits under the State plan for the State plan year or portion of the plan year after a change in benefits that affects the applicability of the aggregate lifetime or annual dollar limits. (42 CFR 457.496(c)(3))

The State assures that it has developed a reasonable methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable. Guidance: Please include the state’s methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit and the results as an attachment to the State child health plan.

6.2.4.3.1- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to a lifetime dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3

6.2.4.3.2- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to an annual dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3 Guidance: If an aggregate lifetime limit is applied to less than one-third of all medical/surgical benefits, the State may not impose an aggregate lifetime limit on any mental health or substance use disorder benefits. If an annual dollar limit is applied to less than one-third of all medical surgical benefits, the State may not impose an annual dollar limit on any mental health or

16 substance use disorder benefits (42 CFR 457.496(c)(1)). Skip to section 6.2.5- MHPAEA.

If the State applies an aggregate lifetime or annual dollar limit to at least one-third of all medical/surgical benefits, please continue below to provide the assurances related to the determination of the portion of total costs for medical/surgical benefits that are subject to either an annual or lifetime limit.

6.2.4.3.2.1- MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least 1/3 and less than 2/3 of all medical/surgical benefits, the State assures the following (42 CFR 457.496(c)(4)(i)(B)); (42 CFR 457.496(c)(4)(ii)):

The State applies an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no more restrictive than an average limit calculated for medical/surgical benefits. Guidance: The state’s methodology for calculating the average limit for medical/surgical benefits must be consistent with 42 CFR 457.496(c)(4)(i)(B) and 42 CFR 457.496(c)(4)(ii). Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.4.3.2.2- MHPAEA If at least 2/3 of all medical/surgical benefits are subject to an annual or lifetime limit, the State assures either of the following (42 CFR 457.496(c)(2)(i)); (42 CFR 457.496(c)(2)(ii)):

The aggregate lifetime or annual dollar limit is applied to both medical/surgical benefits and mental health and substance use disorder benefits in a manner that does not distinguish between medical/surgical benefits and mental health and substance use disorder benefits; or The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefits is no more restrictive than the aggregate lifetime or annual dollar limit on medical/surgical benefits. Quantitative Treatment Limitations

17 6.2.5- MHPAEA Does the State apply quantitative treatment limitations (QTLs) on any mental health or substance use disorder benefits in any classification of benefits? If yes, specify the classification(s) of benefits in which the State applies one or more QTLs on any mental health or substance use disorder benefits.

Yes (Specify: ) No Guidance: If the state does not apply any type of QTLs on any mental health or substance use disorder benefits in any classification, the state meets parity requirements for QTLs and should continue to Section 6.2.6 - MHPAEA. If the state does apply QTLs to any mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue.

6.2.5.1- MHPAEA Does the State apply any type of QTL on any medical/surgical benefits?

Yes No Guidance: If the State does not apply QTLs on any medical/surgical benefits, the State may not impose quantitative treatment limitations on mental health or substance use disorder benefits, please go to Section 6.2.6- MHPAEA related to non- quantitative treatment limitations.

6.2.5.2- MHPAEA Within each classification of benefits in which the State applies a type of QTL on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the classification which are subject to the limitation. More specifically, the State must determine the ratio of (a) the dollar amount of all payments expected to be paid under the State plan for medical and surgical benefits within a classification which are subject to the type of quantitative treatment limitation for the plan year (or portion of the plan year after a mid-year change affecting the applicability of a type of quantitative treatment limitation to any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all medical and surgical benefits within the classification for the plan year. For purposes of this paragraph, all payments expected to be paid under the State plan includes payments expected to be made directly by the State and payments which are expected to be made by MCEs contracting with the State. (42 CFR 457.496(d)(3)(i)(C))

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above for each classification within which the State applies QTLs to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E))

18 Guidance: Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.5.3- MHPAEA For each type of QTL applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of QTL to “substantially all” (defined as at least two-thirds) of the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of QTL to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose that type of QTL on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

6.2.5.3.1- MHPAEA For each type of QTL applied to mental health or substance use disorder benefits, the State must determine the predominant level of that type which is applied to medical/surgical benefits in the classification. The “predominant level” of a type of QTL in a classification is the level (or least restrictive of a combination of levels) that applies to more than one-half of the medical/surgical benefits in that classification, as described in 42 CFR 457.496(d)(3)(i)(B). The portion of medical/surgical benefits in a classification to which a given level of a QTL type is applied is based on the dollar amount of payments expected to be paid for medical/surgical benefits subject to that level as compared to all medical/surgical benefits in the classification, as described in 42 CFR 457.496(d)(3)(i)(C). For each type of quantitative treatment limitation applied to mental health or substance use disorder benefits, the State assures:

The same reasonable methodology applied in determining the dollar amounts used to determine whether substantially all medical/surgical benefits within a classification are subject to a type of quantitative treatment limitation also is applied in determining the dollar amounts used to determine the predominant level of a type of quantitative treatment limitation applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of quantitative treatment limitation applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i))

19 Guidance: If there is no single level of a type of QTL that exceeds the one- half threshold, the State may combine levels within a type of QTL such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

Non-Quantitative Treatment Limitations

6.2.6- MHPAEA The State may utilize non-quantitative treatment limitations (NQTLs) for mental health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all the mental health parity requirements. (42 CFR 457.496(d)(4)); (42 CFR 457.496(d)(5)) 6.2.6.1 – MHPAEA If the State imposes any NQTLs, complete this subsection. If the State does not impose NQTLs, please go to Section 6.2.7-MHPAEA.

The State assures that the processes, strategies, evidentiary standards or other factors used in the application of any NQTL to mental health or substance use disorder benefits are no more stringent than the processes, strategies, evidentiary standards or other factors used in the application of NQTLs to medical/surgical benefits within the same classification. Guidance: Examples of NQTLs include medical management standards to limit or exclude benefits based on medical necessity, restrictions based on geographic location, provider specialty, or other criteria to limit the scope or duration of benefits and provider network design (ex: preferred providers vs. participating providers). Additional examples of possible NQTLs are provided in 42 CFR 457.496(d)(4)(ii). States will need to provide a summary of its NQTL analysis, as well as supporting documentation as requested.

6.2.6.2 – MHPAEA The State or MCE contracting with the State must comply with parity if they provide coverage of medical or surgical benefits furnished by out-of-network providers.

6.2.6.2.1- MHPAEA Does the State or MCE contracting with the State provide

coverage of medical or surgical benefits provided by out-of-network providers?

Yes No Guidance: The State can answer no if the State or MCE only provides out of network services in specific circumstances, such as emergency care, or when the network is unable to provide a necessary service covered under the contract.

20

6.2.6.2.2- MHPAEA If yes, the State must provide access to out-of-network providers for mental health or substance use disorder benefits. Please assure the following:

The State attests that when determining access to out-of-network providers within a benefit classification, the processes, strategies, evidentiary standards, or other factors used to determine access to those providers for mental health/ substance use disorder benefits are comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors used to determine access for out- of-network providers for medical/surgical benefits. Availability of Plan Information 6.2.7- MHPAEA The State must provide beneficiaries, potential enrollees, and providers with information related to medical necessity criteria and denials of payment or reimbursement for mental health or substance use disorder services (42 CFR 457.496(e)) in addition to existing notice requirements at 42 CFR 457.1180.

6.2.7.1- MHPAEA Medical necessity criteria determinations must be made available to any current or potential enrollee or contracting provider, upon request. The state attests that the following entities provide this information:

State Managed Care entities Both Other

Guidance: If other is selected, please specify the entity.

6.2.7.2- MHPAEA Reason for any denial for reimbursement or payment for

mental health or substance use disorder benefits must be made available to the

enrollee by the health plan or the State. The state attests that the following

entities provide denial information:

State Managed Care entities Both

21 Other

Guidance: If other is selected, please specify the entity.

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

8.4.1.

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42 CFR 457.530) 8.4.2.

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

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

8.4.1- MHPAEA There is no separate accumulation of cumulative financial requirements, as defined in 42 CFR 457.496(a), for mental health and substance abuse disorder benefits compared to medical/surgical benefits. (42 CFR 457.496(d)(3)(iii))

8.4.2- MHPAEA If applicable, any different levels of financial requirements that are applied to different tiers of prescription drugs are determined based on reasonable factors, regardless of whether a drug is generally prescribed for medical/surgical benefits or mental health/substance use disorder benefits. (42 CFR 457.496(d)(3)(ii)(A))

8.4.3- MHPAEA Cost sharing applied to benefits provided under the State child health plan will remain capped at five percent of the beneficiary’s income as required by 42 CFR 457.560 (42 CFR 457.496(d)(3)(i)(D)).

8.4.4- MHPAEA Does the State apply financial requirements to any mental health or substance use disorder benefits? If yes, specify the classification(s) of benefits in which the State applies financial requirements on any mental health or substance use disorder benefits.

Yes (Specify: Wyoming CHIP applies a co-payment to all services, both medical/surgical and MH/SUD, as outlined in Section 8.) No Guidance: For the purposes of parity, financial requirements include deductibles, copayments, coinsurance, and out of pocket maximums; premiums are excluded from the definition. If the state does not apply financial requirements on any mental health or substance use disorder benefits, the state meets parity requirements for financial requirements. If the state does apply financial requirements to mental health or substance use disorder benefits, the state must

22 conduct a parity analysis. Please continue below.

Please ensure that changes made to financial requirements under the State child health plan as a result of the parity analysis are also made in Section 8.2.

8.4.5- MHPAEA Does the State apply any type of financial requirements on any medical/surgical benefits?

Yes No Guidance: If the State does not apply financial requirements on any medical/surgical benefits, the State may not impose financial requirements on mental health or substance use disorder benefits.

8.4.6- MHPAEA Within each classification of benefits in which the State applies a type of financial requirement on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the class which are subject to the limitation.

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above (Section 6.2.5.2-MHPAEA) for each classification or within which the State applies financial requirements to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) Guidance: Please include the state’s methodology and results of the parity analysis as an attachment to the State child health plan.

8.4.7- MHPAEA For each type of financial requirement applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of financial requirement to at least two-thirds (“substantially all”) of all the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of financial requirement to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose financial requirements on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

23

8.4.8- MHPAEA For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State must determine the predominant level (as defined in 42 CFR 457.496(d)(3)(i)(B)) of that type which is applied to medical/surgical benefits in the classification. For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State assures:

The same reasonable methodology applied in determining the dollar amounts used in determining whether substantially all medical/surgical benefits within a classification are subject to a type of financial requirement also is applied in determining the dollar amounts used to determine the predominant level of a type of financial requirement applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of financial requirement applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of financial requirement that exceeds the one-half threshold, the State may combine levels within a type of financial requirement such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

24 Key for Newly Incorporated Templates The newly incorporated templates are indicated with the following letters after the numerical section throughout the template.

• PC- Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • PW- Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • TC- Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • DC- Dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • DS- Supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • PA- Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • EL- Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • LR- Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010)

Region 1-

Connecticut

New Hampshire

Richard R. McGreal

John F. Kennedy Federal Bldg.

Boston Massachuset | Rhode Island richard.mcgreal@cms.hhs.gov | Room 2275 ts ‘Vermont Boston, MA 02203-0003 Maine Region 2- New York New Jersey Michael Melendez 26 Federal Plaza New York Virgin Puerto Rico michael.melendez@cms.hhs.gov } Room 3811 Islands New York, NY 10278-0063 Region 3- Delaware Pennsylvania Ted Gallagher The Public Ledger Building Philadelphia | District of Virginia ted.gallagher@cms.hhs.gov 150 South Independence Mall Columbia West Virginia West Maryland Suite 216 Philadelphia, PA 19106 Region 4- Alabama Mississippi Jackie Glaze Atlanta Federal Center Atlanta Florida North Carolina jackie.glaze@cms.hhs.gov 4% Floor Georgia South Carolina 61 Forsyth Street, S.W. Kentucky Tennessee Suite 4T20 Atlanta, GA 30303-8909 Region 5- Illinois Minnesota Verlon Johnson 233 North Michigan Avenue, Chicago Indiana Ohio verlon.johnson@cms.hhs.gov | Suite 600 Michigan Wisconsin Chicago, IL 60601 Region 6- Arkansas Oklahoma Bill Brooks 1301 Young Street, 8th Floor Dallas Louisiana Texas bill.brooks@cms.hhs.gov Dallas, TX 75202 New Mexico Region 7- Towa Missouri James G. Scott Richard Bulling Federal Bldg. Kansas City | Kansas Nebraska james.scott](@cms.hhs.gov 601 East 12 Street, Room 235 Kansas City, MO 64106-2808 Region 8- Colorado South Dakota Richard Allen Federal Office Building, Room Denver Montana Utah richard.allen@cms.hhs.gov 522 1961 Stout Street North Wyoming Denver, CO 80294-3538 Dakota Region 9- Arizona American Gloria Nagle 90 Seventh Street Suite 5-300 San California Samoa gloria.nagle@cms.hhs. gov San Francisco Federal Building Francisco Hawaii Guam San Francisco, CA 94103 Nevada Northern

Mariana Islands

25

26

Region 10- Seattle Idaho Washington Alaska Oregon Carol Peverly carol.peverly@cms.hhs.gov 2001 Sixth Avenue MS RX-43 Seattle, WA 98121

27 GLOSSARY Adapted directly from Sec. 2110. DEFINITIONS. CHILD HEALTH ASSISTANCE- For purposes of this title, the term ‘child health assistance’ means payment for part or all of the cost of health benefits coverage for targeted low-income children that includes any of the following (and includes, in the case described in Section 2105(a)(2)(A), payment for part or all of the cost of providing any of the following), as specified under the State plan: 1. Inpatient hospital services. 2. Outpatient hospital services. 3. Physician services. 4. Surgical services. 5. Clinic services (including health center services) and other ambulatory health care services. 6. Prescription drugs and biologicals and the administration of such drugs and biologicals, only if such drugs and biologicals are not furnished for the purpose of causing, or assisting in causing, the death, suicide, euthanasia, or mercy killing of a person. 7. Over-the-counter medications. 8. Laboratory and radiological services. 9. Prenatal care and prepregnancy family planning services and supplies. 10. Inpatient mental health services, other than services described in paragraph (18) but including services furnished in a State-operated mental hospital and including residential or other 24-hour therapeutically planned structured services. 11. Outpatient mental health services, other than services described in paragraph (19) but including services furnished in a State-operated mental hospital and including community-based services. 12. Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices). 13. Disposable medical supplies. 14. Home and community-based health care services and related supportive services (such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home). 15. Nursing care services (such as nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services) in a home, school, or other setting. 16. Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. 17. Dental services. 18. Inpatient substance abuse treatment services and residential substance abuse treatment services. 19. Outpatient substance abuse treatment services. 20. Case management services. 21. Care coordination services. 22. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders.

28 23. Hospice care. 24. Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services (whether in a facility, home, school, or other setting) if recognized by State law and only if the service is-- a. prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as defined by State law, b. performed under the general supervision or at the direction of a physician, or c. furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license. 25. Premiums for private health care insurance coverage. 26. Medical transportation. 27. Enabling services (such as transportation, translation, and outreach services) only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals. 28. Any other health care services or items specified by the Secretary and not excluded under this section.

TARGETED LOW-INCOME CHILD DEFINED- For purposes of this title-- 1. IN GENERAL- Subject to paragraph (2), the term ‘targeted low-income child’ means a child-- a. who has been determined eligible by the State for child health assistance under the State plan; b. (i) who is a low-income child, or (ii) is a child whose family income (as determined under the State child health plan) exceeds the Medicaid applicable income level (as defined in paragraph (4)), but does not exceed 50 percentage points above the Medicaid applicable income level; and c. who is not found to be eligible for medical assistance under title XIX or covered under a group health plan or under health insurance coverage (as such terms are defined in Section 2791 of the Public Health Service Act). 2. CHILDREN EXCLUDED- Such term does not include-- a. a child who is a resident of a public institution or a patient in an institution for mental diseases; or b. a child who is a member of a family that is eligible for health benefits coverage under a State health benefits plan on the basis of a family member's employment with a public agency in the State. 3. SPECIAL RULE- A child shall not be considered to be described in paragraph (1)(C) notwithstanding that the child is covered under a health insurance coverage program that has been in operation since before July 1, 1997, and that is offered by a State which receives no Federal funds for the program's operation. 4. MEDICAID APPLICABLE INCOME LEVEL- The term ‘Medicaid applicable income level’ means, with respect to a child, the effective income level (expressed as a percent of the poverty line) that has been specified under the State plan under title XIX (including under a waiver authorized by the Secretary or under Section 1902(r)(2)), as of June 1, 1997, for the child to be eligible for medical

29 assistance under Section 1902(l)(2) for the age of such child. 5. TARGETED LOW-INCOME PREGNANT WOMAN.—The term ‘targeted low-income pregnant woman’ means an individual— (A) during pregnancy and through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends; (B) whose family income exceeds 185 percent (or, if higher, the percent applied under subsection (b)(1)(A)) of the poverty line applicable to a family of the size involved, but does not exceed the income eligibility level established under the State child health plan under this title for a targeted low-income child; and (C) who satisfies the requirements of paragraphs (1)(A), (1)(C), (2), and (3) of Section 2110(b) in the same manner as a child applying for child health assistance would have to satisfy such requirements.

ADDITIONAL DEFINITIONS- For purposes of this title: 1. CHILD- The term ‘child’ means an individual under 19 years of age. 2. CREDITABLE HEALTH COVERAGE- The term ‘creditable health coverage’ has the meaning given the term ‘creditable coverage’ under Section 2701(c) of the Public Health Service Act (42 U.S.C. 300gg(c)) and includes coverage that meets the requirements of section 2103 provided to a targeted low-income child under this title or under a waiver approved under section 2105(c)(2)(B) (relating to a direct service waiver). 3. GROUP HEALTH PLAN; HEALTH INSURANCE COVERAGE; ETC- The terms ‘group health plan’, ‘group health insurance coverage’, and ‘health insurance coverage’ have the meanings given such terms in Section 2191 of the Public Health Service Act. 4. LOW-INCOME CHILD - The term ‘low-income child’ means a child whose family income is at or below 200 percent of the poverty line for a family of the size involved. 5. POVERTY LINE DEFINED- The term ‘poverty line’ has the meaning given such term in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section. 6. PREEXISTING CONDITION EXCLUSION- The term ‘preexisting condition exclusion’ has the meaning given such term in section 2701(b)(1)(A) of the Public Health Service Act (42 U.S.C. 300gg(b)(1)(A)). 7. STATE CHILD HEALTH PLAN; PLAN- Unless the context otherwise requires, the terms ‘State child health plan’ and ‘plan’ mean a State child health plan approved under Section 2106. 8. UNINSURED CHILD- The term ‘uninsured child’ means a child that does not have creditable health coverage.

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Wyoming WY-21-0017

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-01-16 < Ry] Ss Baltimore, MD 21244-1850

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

Children and Adults Health Programs Group

May 25, 2021

Heather Gifford

Kid Care CHIP Manager Wyoming Department of Health Division of Healthcare Financing 122 West 25" Street, 4 West Cheyenne, WY 82002

Dear Ms. Gifford:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA), WY- 21-0017, submitted on January 5, 2021 and WY-21-0018, submitted on March 15, 2021, with additional information submitted on May 25, 2021, has been approved. These SPAs allow the state to transition its separate CHIP program, Kid Care CHIP, to a Medicaid expansion program effective as of October 1, 2020.

Through SPA WY-21-0017, the state removes references to its separate CHIP program throughout the state plan. This population transitioned to Wyoming’s Medicaid state plan through Medicaid SPA WY-20-0008. SPA WY-21-0018 updates the income standards for the state’s Medicaid expansion CHIP.

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

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

E-mail: Joyce.Jordan@cms.hhs.gov

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

Sincerely,

/Signed by Amy Lutzky/

Amy Lutzky Deputy Director

Effective Date: October 1, 2020

Approval Date:

OMB #: 0938-0707 Exp. Date:

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

Preamble

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

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

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

Form CMS-R-211

Effective Date: October 1, 2020

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

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

State/Territory: Wyoming (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR 457.40(b)) ____________________________________________________________________________________ Teri Green, State Medicaid Director (Signature of Governor, or designee, of State/Territory, Date Signed)

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

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

Name: Coleen Collins

Position/Title: Eligibility Services Administrator Name: Heather Gifford

Position/Title: Kid Care CHIP Manager

Name:

Position/Title:

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

Effective Date: October 1, 2020

Approval Date: Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 105-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the program.

This template outlines the information that must be included in the state plans and the state plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: • Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. • Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) • Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. • Removed crowd-out language that had been added by the August 17 letter that later was repealed. The Centers for Medicare & Medicaid Services (CMS) is developing regulations to implement the CHIPRA requirements. When final regulations are published in the Federal Register, this template will be modified to reflect those rules and States will be required to submit SPAs illustrating compliance with the new regulations. States are not required to resubmit their State plans based on the updated template. However, States must use the updated template when submitting a State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a

Effective Date: October 1, 2020

Approval Date: complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

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

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires a description that must include both proposed methods of delivery and proposed utilization control systems. This section should fully describe the delivery system of the Title XXI program including the proposed contracting standards, the proposed delivery systems and the plans for enrolling providers. (Section 2103); (42 CFR 457.410(A)) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42 CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of

Effective Date: October 1, 2020

Approval Date: any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary-approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre-existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Effective Date: October 1, 2020

Approval Date: Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: • Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. • Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State Plan Amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children’s Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections)

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an

Effective Date: October 1, 2020

Approval Date: expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

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

Effective Date: October 1, 2020

Approval Date: Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)(1)); (42 CFR 457.70):

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

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

Overview

The State of Wyoming will implement a State Children’s Health Insurance Program (SCHIP) based on Title XXI of the Social Security Act.

Kid Care CHIP is not an entitlement program. The legislature will appropriate funds for Kid Care CHIP each biennium. Enrollment will be based on funding. Enrollment will be monitored on a monthly basis and if based on the monitoring, it is determined that funds will not be available to continue the program, enrollment will be suspended via an approved enrollment freeze until adequate funding is available.

This is amendment six and replaces any previous amendments.

The existing Department of Health infrastructure will be used to support this program whenever possible.

Wyoming assures that it will conduct Kid Care CHIP in compliance with all applicable civil rights requirements.

Children up to age 19 in families up to 200% of the federal poverty level (FPL), who are uninsured and are not eligible for Medicaid will be eligible for Kid Care CHIP. The following chart displays the current age and income requirements in relation to the federal poverty level (FPL) for Medicaid and Kid Care CHIP.

Effective Date: October 1, 2020

Approval Date:

The Children’s Health Insurance Program within the Office of Health Care Financing of the Wyoming Department of Health (WDH), will administer Kid Care CHIP.

The proposed effective date for the expansion of Kid Care CHIP is October 1, 2009.

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

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

Overview

The State of Wyoming has implemented a State Children’s Health Insurance Program (MCHIP) based on Title XXI of the Social Security Act.

The legislature has appropriated funds for Kid Care CHIP each biennium.

The existing Department of Health infrastructure is used to support this program.

Children up to age 19 in families up to 200% of the federal poverty level (FPL), who are uninsured and are not eligible for Medicaid will be eligible for Kid Care CHIP. The following chart displays the current age and income requirements in relation to the federal poverty level (FPL) for Medicaid and Kid Care CHIP.

Effective Date: October 1, 2020

Approval Date:

The Children’s Health Insurance Program within the Division of Healthcare Financing of the Wyoming Department of Health (WDH), administers Kid Care CHIP.

The proposed effective date for the expansion of Kid Care CHIP is October 1, 2020.

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

1.1.3. A combination of both of the above. (Section 2101(a)(2))

1.1-DS

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

1.2.

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

Wyoming assures that any expenditure for Kid Care CHIP will not be claimed prior to receiving Legislative authority to operate the plan or plan amendment as approved by CMS.

1.3.

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

Effective Date: October 1, 2020

Approval Date:

Wyoming assures that it complies with all applicable civil rights requirements.

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

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

Original State Plan:

Effective Date:

4/1/99

Implementation Date: 12/1/99

Amendment #1:

Effective Date:

June 13, 2001

Implementation Date: Not implemented

Amendment #2:

Effective Date:

July 1, 2002

Implementation Date: July 1, 2002

Amendment #3:

Effective Date:

July 1, 2003

Implementation Date: July 1, 2003

Amendment #4:

Effective Date:

July 1, 2005

Implementation Date: July 1, 2005

Amendment #5:

Effective Date:

July 1, 2007

Implementation Date: July 1, 2007

Amendment #6:

Effective Date:

October 1, 2009

Implantation Date:

October 1, 2009

Amendment #7:

Mental Health Parity, Medically Necessary Orthodontia & Medically Necessary &

Effective Date: October 1, 2020

Approval Date: Dental Services

Effective Date:

July 1, 2010

Implementation Date: July 1, 2010

Prospective Payment System to FQHC’s and RHC’s

Effective date:

October 1, 2009

Implementation date: September 1, 2010

Transmittal Number SPA Group PDF# Description Superseded Plan Section(s) WY-13-0011

Approval date: 05/09/14 Effective/Implementation Date: January 1, 2014 MAGI Eligibility & Methods CS7 Eligibility – Targeted Low Income Children Supersedes the current sections Geographic Area 4.1.1; Age 4.1.2; and Income 4.1.3

Incorporate within a separate subsection under section 4.3 WY-13-0008

Approval Date: 07/22/14 Effective/Implementation Date: January 1, 2014 XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program Supersedes the current Medicaid expansion section 4.0 WY-13-0012

Approval Date: 04/01/14 Effective/Implementation Date: January 1, 2014 Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporate within a separate subsection under section 4.1 WY-13-0009

Approval Date: 04/08/14 Effective/Implementation Date: October 1, 2013 Eligibility Processing CS24 Eligibility Process Supersedes the current sections 4.3 and 4.4

Effective Date: October 1, 2020

Approval Date: WY-13-0010

Approval Date: 07-10-14 Effective/Implementation Date: January 1, 2014 Non- Financial Eligibility CS17

CS 18

CS19

CS20

CS27 Non-Financial Eligibility – Residency Non-Financial Eligibility – Citizenship

Non-Financial Eligibility – Social Security Number Non-Financial Eligibility – Substitution of Coverage Non-Financial Eligibility – Continuous Eligibility Supersedes the current section 4.1.5 Supersedes the current sections 4.1.0; 4.1- LR; 4.1.1-LR Supersedes the current section 4.1.9.1

Supersedes the current section 4.4.4

Supersedes the current section 4.1.8

SPA #WY-18-0013 Purpose of SPA: Demonstrate compliance with the Mental Health Parity and Addiction Equity Act of 2008. Effective date:

October 2, 2017 Implementation date: October 2, 2017

SPA #WY-19-0014 Purpose of SPA: Managed Care requirements This SPA was withdrawn and not implemented.

SPA #WY-20-0015 Purpose of SPA: To implement provisions for temporary adjustments to enrollment and redetermination policies and cost sharing requirements for children in families living and working in State or Federally declared natural or public health emergency disaster area. In the event of a natural disaster or public health emergency, the State will notify CMS that it intends to provide temporary adjustments to its enrollment and/or redetermination policies and cost sharing requirements; the effective and duration date of such adjustments, and the applicable State declared disaster areas. Proposed effective date: March 12, 2020 Proposed implementation date: March 1, 2020

Effective Date: October 1, 2020

Approval Date:

SPA #WY-20-0016 Purpose of SPA: Access to Mental Health and Substance Use Disorder Services for Children and Pregnant Women in the Children’s Health Insurance Program. Wyoming CHIP will be moved in-house effective October 1, 2020. This SPA documents current benefits as of October 24, 2019. A new state plan or state plan amendment will be submitted prior to October 1, 2020. This SPA was withdrawn and not implemented.

SPA #WY-21-0017 Purpose of SPA: Transition from separate CHIP to expansion CHIP. Proposed effective date: October 1, 2020 Proposed implementation date: October 1, 2020

SPA #WY-21-0018 Purpose of SPA: Transition from separate CHIP to Medicaid expansion CHIP. Proposed effective date: October 1, 2020 Proposed implementation date: October 1, 2020

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. Tribal consultation was sent via email on August 6, 2020, to these tribal organizations: IHS, Northern Arapaho, Eastern Shoshone, and Wind River Cares. No response was received as of the date of this SPA submission. If response is received after this date, the Wyoming Department of Health will address Tribal comments at that time.

Effective Date: October 1, 2020

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

Guidance: The demographic information requested in 2.1. can be used for State planning and will be used strictly for informational purposes. THESE NUMBERS WILL NOT BE USED AS A BASIS FOR THE ALLOTMENT.

Factors that the State may consider in the provision of this information are age breakouts, income brackets, definitions of insurability, and geographic location, as well as race and ethnicity. The State should describe its information sources and the assumptions it uses for the development of its description. • Population • Number of uninsured • Race demographics • Age Demographics • Info per region/Geographic information

2.1. Describe the extent to which, and manner in which, children in the State (including targeted low- income children and other groups of children specified) identified , by income level and other relevant factors, such as race, ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, distinguish between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (Section 2102(a)(1)); (42 CFR 457.80(a))

Health Insurance

Of the 138,920 children under age 19 in the state, it is estimated that 9,475 are uninsured, according to the 2018 Small Area Health Insurance Estimate from the US Census Bureau. Approximately 4,217 are children in families at or below 200% of the federal poverty level (FPL

Uninsured children, eligible for Kid Care CHIP, are targeted for enrollment through the state’s marketing and outreach efforts, coordination with other public and private programs, and through partnerships created across the state with other agencies, organizations and non-profits.

The number of children eligible for Kid Care CHIP was determined using population and uninsured data adjusted to capture income and age eligible children.

Race and Ethnicity Statewide

According to the US Census Bureau's 2018 American Community Survey, the majority of Wyoming residents identify as white. In addition, 10% of Wyoming residents are of Hispanic origin. See the table below for more information on race and ethnicity in Wyoming. 2018 Wyoming Race and Ethnicity Profile American Community Survey, US Census Bureau

Effective Date: October 1, 2020

Approval Date: DEMOGRAPHIC AND HOUSING ESTIMATES

Race/Ethnicity Number Percent Total Population 577,737 100.0 White 528,453 91.47% Black 3,667 0.63% American Indian, Eskimo, or Aleut 16,185 2.80% Asian or Pacific Islander 5,807 1.01% Two or more races 13,716 2.37% Hispanic Origin (of any race) 57,895 10.02%

Wyoming utilizes a variety of approaches to identify and enroll children who may be eligible to participate in EqualityCare (Medicaid) or Kid Care CHIP or to obtain public health services.

Guidance: Section 2.2 allows states to request to use the funds available under the 10 percent limit on administrative expenditures in order to fund services not otherwise allowable. The health services initiatives must meet the requirements of 42 CFR 457.10.

2.2. Health Services Initiatives- Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10)

Wyoming does not have any Health Services Initiatives.

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

Effective Date: October 1, 2020

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

The Wyoming Department of Health has a Tribal Liaison that has an approved process for submitting any state plan amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals, and proposals for demonstration projects in a timely manner to the leaders of the tribes for consultation. The Tribal Liaison also schedules phone calls and meetings as appropriate to discuss any concerns the tribes have.

Effective Date: October 1, 2020

Approval Date:

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

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

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

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

Section 4. Eligibility Standards and Methodology

Guidance: States electing to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan or combination plan should check the appropriate box and provide the ages and income level for each eligibility group. If the State is electing to take up the option to expand Medicaid eligibility as allowed under section 214 of CHIPRA regarding lawfully residing, complete section 4.1-LR as well as update the budget to reflect the additional costs if the state will claim title XXI match for these children until and if the time comes that the children are eligible for Medicaid.

4.0. Medicaid Expansion

4.0.1. Ages of each eligibility group and the income standard for that group:

Available to children from age 6 through age 18 (from 154% to 200% FPL) and children age birth through age 18 (from 119% to 200%). Coverage for children who are eighteen years of age will continue until the child turns 19.

Effective Date: October 1, 2020

Approval Date:

4.1. Separate Program Check all standards that will apply to the State plan. (42CFR 457.305(a) and 457.320(a))

4.1.0 Describe how the State meets the citizenship verification requirements. Include whether or not State has opted to use SSA verification option.

4.1.1 Geographic area served by the Plan if less than Statewide:

4.1.2 Ages of each eligibility group, including unborn children and pregnant women (if applicable) and the income standard for that group:

4.1.2.1-PC Age: through birth (SHO #02-004, issued November 12, 2002)

4.1.3 Income of each separate eligibility group (if applicable):

4.1.3.1-PC 0% of the FPL (and not eligible for Medicaid) through % of the FPL (SHO #02-004, issued November 12, 2002) 4.1.4 Resources of each separate eligibility group (including any standards relating to spend downs and disposition of resources):

4.1.5 Residency (so long as residency requirement is not based on length of time in state):

4.1.6 Disability Status (so long as any standard relating to disability status does not restrict eligibility):

4.1.7 Access to or coverage under other health coverage:

4.1.8 Duration of eligibility, not to exceed 12 months:

4.1.9 Other Standards- Identify and describe other standards for or affecting eligibility, including those standards in 457.310 and 457.320 that are not addressed above. For instance:

Guidance: States may only require the SSN of the child who is applying for coverage. If SSNs are required and the State covers unborn children,

Effective Date: October 1, 2020

Approval Date: indicate that the unborn children are exempt from providing a SSN. Other standards include, but are not limited to presumptive eligibility and deemed newborns.

4.1.9.1 States should specify whether Social Security Numbers (SSN) are required.

Guidance: States should describe their continuous eligibility process and populations that can be continuously eligible.

4.1.9.2 Continuous eligibility:

4.1-PW

Pregnant Women Option (section 2112)- The State includes eligibility for one or more populations of targeted low-income pregnant women under the plan. Describe the population of pregnant women that the State proposes to cover in this section. Include all eligibility criteria, such as those described in the above categories (for instance, income and resources) that will be applied to this population. Use the same reference number system for those criteria (for example, 4.1.1-P for a geographic restriction). Please remember to update sections 8.1.1-PW, 8.1.2-PW, and 9.10 when electing this option.

Guidance: States have the option to cover groups of “lawfully residing” children and/or pregnant women. States may elect to cover (1) “lawfully residing” children described at section 2107(e)(1)(J) of the Act; (2) “lawfully residing” pregnant women described at section 2107(e)(1)(J) of the Act; or (3) both. A state electing to cover children and/or pregnant women who are considered lawfully residing in the U.S. must offer coverage to all such individuals who meet the definition of lawfully residing, and may not cover a subgroup or only certain groups. In addition, states may not cover these new groups only in CHIP, but must also extend the coverage option to Medicaid. States will need to update their budget to reflect the additional costs for coverage of these children. If a State has been covering these children with State only funds, it is helpful to indicate that so CMS understands the basis for the enrollment estimates and the projected cost of providing coverage. Please remember to update section 9.10 when electing this option.

4.1- LR

Lawfully Residing Option (Sections 2107(e)(1)(J) and 1903(v)(4)(A); (CHIPRA # 17, SHO # 10-006 issued July 1, 2010) Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) regarding lawfully residing to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following: A child or pregnant woman shall be considered lawfully present if he or she is: (1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641);

Effective Date: October 1, 2020

Approval Date: (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission; (3) An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; (4) An alien who belongs to one of the following classes: (i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101- 649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status; (5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least180 days; (6) An alien who has been granted withholding of removal under the Convention Against Torture; (7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. §1101(a)(27)(J)); (8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

Elected for pregnant women. Elected for children under age

4.1.1-LR The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA Lawfully Residing option, it has verified,

Effective Date: October 1, 2020

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

4.1-DS

Supplemental Dental (Section 2103(c)(5) - A child who is eligible to enroll in dental- only supplemental coverage, effective January 1, 2009. Eligibility is limited to only targeted low-income children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer. The State’s CHIP plan income eligibility level is at least the highest income eligibility standard under its approved State child health plan (or under a waiver) as of January 1, 2009. All who meet the eligibility standards and apply for dental-only supplemental coverage shall be provided benefits. States choosing this option must report these children separately in SEDS. Please update sections 1.1-DS, 4.2-DS, and 9.10 when electing this option.

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

4.2.1. These standards do not discriminate on the basis of diagnosis.

4.2.2. Within a defined group of covered targeted low-income children, these

standards do not cover children of higher income families without covering

children with a lower family income. This applies to pregnant women included

in the State plan as well as targeted low-income children.

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

medical condition. This applies to pregnant women as well as targeted low-

income children.

4.2-DS Supplemental Dental - Please update sections 1.1-DS, 4.1-DS, and 9.10 when electing this option. For dental-only supplemental coverage, the State assures that it has made the following findings with standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

4.2.1-DS These standards do not discriminate on the basis of diagnosis.

4.2.2-DS Within a defined group of covered targeted low-income children, these

standards do not cover children of higher income families without covering

children with a lower family income.

4.2.3-DS These standards do not deny eligibility based on a child having a pre-

existing medical condition.

Effective Date: October 1, 2020

Approval Date: 4.3. Methodology. Describe the methods of establishing and continuing eligibility and enrollment. The description should address the procedures for applying the eligibility standards, the organization and infrastructure responsible for making and reviewing eligibility determinations, and the process for enrollment of individuals receiving covered services, and whether the State uses the same application form for Medicaid and/or other public benefit programs. (Section 2102)(b)(2)) (42CFR, 457.350)

Guidance: The box below should be checked as related to children and pregnant women. Please note: A State providing dental-only supplemental coverage may not have a waiting list or limit eligibility in any way.

4.3.1. Limitation on Enrollment Describe the processes, if any, that a State will use for instituting enrollment caps, establishing waiting lists, and deciding which children will be given priority for enrollment. If this section does not apply to your state, check the box below. (Section 2102(b)(2)) (42CFR, 457.305(b))

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

Guidance: Note that for purposes of presumptive eligibility, States do not need to verify the citizenship status of the child. States electing this option should indicate so in the

State plan. (42 CFR 457.355)

4.3.2. Check if the State elects to provide presumptive eligibility for children that meets the requirements of section 1920A of the Act. (Section 2107(e)(1)(L)); (42 CFR 457.355)

Guidance: Describe how the State intends to implement the Express Lane option. Include information on the identified Express Lane agency or agencies, and whether the State will be using the Express Lane eligibility option for the initial eligibility determinations, redeterminations, or both.

4.3.3-EL Express Lane Eligibility Check here if the state elects the option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of CHIP eligibility. The state agrees to comply with the requirements of sections 2107(e)(1)(E) and 1902(e)(13) of the Act for this option. Please update sections 4.4-EL, 5.2-EL, 9.10, and 12.1 when electing this option. This authority may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013. (Section 2107(e)(1)(E))

4.3.3.1-EL Also indicate whether the Express Lane option is applied to (1) initial eligibility determination, (2) redetermination, or (3) both.

Effective Date: October 1, 2020

Approval Date:

4.3.3.2-EL List the public agencies approved by the State as Express Lane agencies.

4.3.3.3-EL List the components/components of CHIP eligibility that are determined under the Express Lane. In this section, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between CHIP eligibility determinations for such children and the determination under the Express Lane option.

4.3.3.3-EL List the component/components of CHIP eligibility that are determined under the Express Lane.

4.3.3.4-EL Describe the option used to satisfy the screen and enrollment requirements before a child may be enrolled under title XXI.

Guidance: States should describe the process they use to screen and enroll children required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 457.80(c). Describe the screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by an Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated. Describe whether the State is temporarily enrolling children in CHIP, based on the income finding from an Express Lane agency, pending the completion of the screen and enroll process.

In this section, states should describe their eligibility screening process in a way that addresses the five assurances specified below. The State should consider including important definitions, the relationship with affected Federal, State and local agencies, and other applicable criteria that will describe the State’s ability to make assurances. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)), (42 CFR 457.310(b)(2), 42CFR 457.350(a)(1) and 457.80(c)(3))

4.4. Eligibility screening and coordination with other health coverage programs States must describe how they will assure that:

4.4.1. only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance (including access to a State health benefits plan) are furnished child health assistance under the plan. (Sections 2102(b)(3)(A), 2110(b)(2)(B)) (42 CFR 457.310(b), 42 CFR

Effective Date: October 1, 2020

Approval Date: 457.350(a)(1) and 42 CFR 457.80(c)(3)) Confirm that the State does not apply a waiting period for pregnant women.

4.4.2. children found through the screening process to be potentially eligible for medical assistance under the State Medicaid plan are enrolled for assistance under such plan; (Section 2102(b)(3)(B)) (42CFR, 457.350(a)(2))

4.4.3. children found through the screening process to be ineligible for Medicaid are enrolled in CHIP; (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

4.4.4. the insurance provided under the State child health plan does not substitute for coverage under group health plans. (Section 2102(b)(3)(C)) (42CFR, 457.805)

4.4.4.1. (formerly 4.4.4.4) If the State provides coverage under a premium assistance program, describe: 1) the minimum period without coverage under a group health plan. This should include any allowable exceptions to the waiting period; 2) the expected minimum level of contribution employers will make; and 3) how cost-effectiveness is determined. (42CFR 457.810(a)-(c))

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

Guidance: When the State is using an income finding from an Express Lane agency, the State must still comply with screen and enroll requirements before enrolling children in CHIP. The State may either continue its current screen and enroll process, or elect one of two new options to fulfill these requirements.

4.4-EL The State should designate the option it will be using to carry out screen and enroll

requirements:

The State will continue to use the screen and enroll procedures required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 42 CFR 457.80(c). Describe this process.

Effective Date: October 1, 2020

Approval Date:

The State is establishing a screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by the Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated.

The State is temporarily enrolling children in CHIP, based on the income finding from the Express Lane agency, pending the completion of the screen and enroll process.

Effective Date: October 1, 2020

Approval Date: Section 5. Outreach and Coordination

5.1. (formerly 2.2) Describe the current State efforts to provide or obtain creditable health coverage for uninsured children by addressing sections 5.1.1 and 5.1.2. (Section 2102)(a)(2) (42CFR 457.80(b))

Guidance: The information below may include whether the state elects express lane eligibility a description of the State’s outreach efforts through Medicaid and state-only programs.

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

Guidance: The State may address the coordination between the public-private outreach and the public health programs that is occurring statewide. This section will provide a historic record of the steps the State is taking to identify and enroll all uninsured children from the time the State’s plan was initially approved. States do not have to rewrite this section but may instead update this section as appropriate.

Wyoming previously worked with the USDA school lunch program to provide outreach materials to parents.

Wyoming previously worked with the Department of Family Service county offices through an interagency agreement to determine eligibility for the Kid Care CHIP program.

Posters, brochures, applications and a 1-800 number provide Medicaid and Kid Care CHIP information to potentially eligible families at numerous locations across the state including public health nursing offices, provider offices, Indian Health Services, local government offices, schools, insurance offices and WIC offices.

Wyoming’s Maternal and Child Health (MCH) Division offered several programs which lead to referrals to Kid Care CHIP. These programs included: Best Beginnings, Home Visiting for Pregnant and Parenting Families and Children’s Special Health (CSH).

Federally Qualified Health Centers - Wyoming has previously worked with 6 federally qualified health centers. These facilities have the resources necessary to determine presumptive eligibility for pregnant women and to make referrals to other programs. These clinics provide health care services and are funded with state and federal funds.

Migrant Health Services - CHIP previously worked with two migrant health programs in Wyoming covering six counties which provided limited service in a clinic setting and

Effective Date: October 1, 2020

Approval Date: provided vouchers for participants to obtain services from private medical providers. These programs are funded by federal funds.

5.1.2. (formerly 2.2.2.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in health insurance programs that involve a public-private partnership:

Kid Care CHIP works with schools, public health offices, and community organizations to share information about the program with potential clients and stakeholders. Kid Care CHIP has worked with the Boys and Girls Clubs throughout the state, the health centers on the Wind River Reservation and creates annual back to school campaigns. Collaborations with school administrators, school nurses, and school counselors have proved to be the most effective outreach strategy for reaching families in need of health insurance. Kid Care CHIP also uses Facebook, a bi-monthly newsletter, and regular text message reminders to share information with clients.

Posters, brochures, an active Facebook page, website, applications and a toll-free number provide Medicaid and Kid Care CHIP information to potentially eligible families at numerous locations across the state including public health nursing offices, provider offices, Indian Health Services, local government offices, schools, insurance offices and WIC offices.

Federally Qualified Health Centers and Rural Health Centers – Through Wyoming Primary Care Association and independently, Wyoming has worked with six federally qualified health centers and rural health clinics throughout the state. These facilities house a health insurance navigator to assist clients in enrolling in the Federally Funded Marketplace and Medicaid and Kid Care CHIP. These clinics provide health care services and are funded with state and federal funds.

Guidance: The State should describe below how it’s Title XXI program will closely coordinate the enrollment with Medicaid because under Title XXI, children identified as Medicaid-eligible are required to be enrolled in Medicaid. Specific information related to Medicaid screen and enroll procedures is requested in Section 4.4. (42CFR 457.80(c))

5.2. (formerly 2.3) Describe how CHIP coordinates with other public and private health insurance programs, other sources of health benefits coverage for children, other relevant child health programs, (such as title V), that provide health care services for low-income children to increase the number of children with creditable health coverage. (Section 2102(a)(3), 2102(b)(3)(E) and 2102(c)(2)) (42CFR 457.80(c)). This item requires a brief overview of how Title XXI efforts – particularly new enrollment outreach efforts – will be coordinated with and improve upon existing State efforts.

A State funded program which provides medical care for foster children in DFS

Effective Date: October 1, 2020

Approval Date: custody is administered by the Division of Healthcare Financing and provides the same level of medical benefits to low income foster children and children in subsidized adoptions who are not eligible for Medicaid or Kid Care CHIP.

Public Health Nursing (PHN) - Thirty-one offices statewide provide direct health services such as immunizations. PHN offices work closely with the Department of Health and with DFS to assure appropriate referrals are made to Kid Care CHIP. Some PHNs determine presumptive eligibility for the Medicaid pregnant woman program. Funding comes from a combination of state, county, and/or federal funds.

Women, Infants and Children’s (WIC) offices statewide provide referral to Kid Care CHIP Medicaid for clients who are income eligible. WIC coordinates with Medicaid by referring clients to Medicaid if appropriate. WIC is funded by the Department of Agriculture.

Wyoming Department of Health Maternal and Child Health (MCH) Division offers several programs which lead to referral to Kid Care CHIP. These programs include:

Healthy Baby Home Visitation Program – This program includes the Best Beginnings Program and the Nurse Family Partnership. Both programs include home visits from public health nurses to assist families in pregnancy and after birth. A mission of both programs is to share resources with families like Kid Care CHIP and Medicaid. Funding comes from a combination of private, state, county, and/or federal funds.

Children’s Special Health (CSH) - This program provides care coordination and case management and some financial assistance for low income children under age 19 up to 200% of the FPL, high-risk mothers who have special health care needs who are not eligible for Medicaid or other health care insurance and infants in Newborn Intensive Care. CSH requires eligible participating children to enroll in Kid Care CHIP and Medicaid. Reciprocally, Kid Care CHIP shares information about CHS to potentially eligible clients. Program activities are funded with state and federal funds.

Indian Health Services (IHS) Clinic - Wyoming has two IHS clinics on the Wind River Indian Reservation. CHIP provides outreach materials to the clinics to assist clients in knowing whether they will qualify for Medicaid or CHIP.

Part C of the Individuals with Disabilities Education Act (IDEA) - The program provides statewide early intervention services to meet the needs of Wyoming’s infants and toddlers with diagnosed disabilities or with developmental delays which warrant concern for future development. Children deemed eligible for Part C Services in Wyoming who appear to be Medicaid eligible are referred to the WDH Customer Service Center for a Medicaid or CHIP determination.

Effective Date: October 1, 2020

Approval Date:

The state’s goal is to provide all targeted low-income children with an accessible and comprehensive system of care that secures a medical home for children. This coordination is directed to ensuring that Kid Care CHIP will not supplant or replace existing programs. Rather, the goal of coordination will be close cooperation between these programs to enhance the health care resources available to low-income children.

The Wyoming Department of Health, the single state agency which administers Medicaid, also administers Kid Care CHIP. This administrative structure has helped to coordinate both Medicaid and CHIP for facilitating enrollment in the respective programs.

5.2-EL The State should include a description of its election of the Express Lane eligibility option to provide a simplified eligibility determination process and expedited enrollment of eligible children into Medicaid or CHIP.

Guidance: Outreach strategies may include, but are not limited to, community outreach workers, out stationed eligibility workers, translation and transportation services, assistance with enrollment forms, case management and other targeting activities to inform families of low-income children of the availability of the health insurance program under the plan or other private or public health coverage.

The description should include information on how the State will inform the target of the availability of the programs, including American Indians and Alaska Natives, and assist them in enrolling in the appropriate program.

5.3. Strategies Describe the procedures used by the State to accomplish outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program. (Section 2102(c)(1)) (42CFR 457.90)

Outreach and Marketing Campaign

Kid Care CHIP uses an outreach and marketing campaign developed by the Kid Care CHIP program to inform families of children likely to be eligible for Kid Care CHIP or other public or private health coverage programs of the availability of these programs and to assist them in enrolling their children.

The Kid Care CHIP program works closely with it community and state wide partners across the state. These partners are a result of work of the previous Covering Kids Coalition and the continuous work of the Kid Care CHIP outreach unit. Our partners include representatives from child advocacy organizations, education organizations, health care provider associations, the insurance industry, and other public and private providers who are concerned with children’s health including:

Effective Date: October 1, 2020

Approval Date:

• American Academy of Pediatrics • Cheyenne Children’s Clinic • Cheyenne Super Day • Child Development Services of Wyoming • Edible Prairie Project • Enroll Wyoming o Safe Kids Campaign • Governor’s Early Childhood Development Council • Indian Health Services • Laramie County Community Partnership • One22 Resource Center • Step Up-Wyoming Tribune Eagle • University of Wyoming • UPLIFT • Wyoming 2-1-1 • Wyoming Afterschool Alliance • Wyoming Association of Municipalities • Wyoming Business Council • Wyoming Chapter, American Academy of Pediatrics • Wyoming Department of Education • Wyoming Department of Family Services • Wyoming Department of Health  Public Health Nursing  Maternal and Child Health  Immunization  Women, Infant and Children Nutrition Program (WIC)  Office of Multicultural Health • Wyoming Head Start Association • Wyoming Health Council • Wyoming Hospital Association • Wyoming Insurance Commissioner’s Office • Wyoming Kids First • Wyoming Medical Society • Wyoming Motel & Restaurant Association • Wyoming Nurses Association • Wyoming Parent Information Center • Wyoming School Nurses Association • Wyoming Youth Services Association

Marketing Methods: Direct appeals are made using radio and television public service announcements, print media, Facebook, and printed materials. Kid Care CHIP specific materials will be developed and will

Effective Date: October 1, 2020

Approval Date: continue to be evaluated and adjusted as needed.

Collaboration: The Kid Care CHIP Program provides education to local organizations and providers by developing materials about Kid Care CHIP, speaking at training sessions, and/or meetings, and by submitting information to professional newsletters and bulletins. Kid Care CHIP will collaborate with the Department of Education on school administrators, principals, secretaries and school nurses to conduct back to school enrollment drives.

Kid Care CHIP works closely with Indian Health Services to develop specific outreach activities that are acceptable to the tribes.

Effective Date: October 1, 2020

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

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan and proceed to Section 7 since children covered under a Medicaid expansion program will receive all Medicaid covered services including EPSDT.

6.1. The State elects to provide the following forms of coverage to children: (Check all that apply.) (Section 2103(c)); (42CFR 457.410(a))

Guidance: Benchmark coverage is substantially equal to the benefits coverage in a benchmark benefit package (FEHBP-equivalent coverage, State employee coverage, and/or the HMO coverage plan that has the largest insured commercial, non-Medicaid enrollment in the state). If box below is checked, either 6.1.1.1., 6.1.1.2., or 6.1.1.3. must also be checked. (Section 2103(a)(1))

6.1.1.

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

Guidance: Check box below if the benchmark benefit package to be offered by the State is the standard Blue Cross/Blue Shield preferred provider option service benefit plan, as described in and offered under Section 8903(1) of Title 5, United States Code. (Section 2103(b)(1) (42 CFR 457.420(b))

6.1.1.1.

FEHBP-equivalent coverage; (Section 2103(b)(1) (42 CFR 457.420(a)) (If checked, attach copy of the plan.)

Guidance: Check box below if the benchmark benefit package to be offered by the State is State employee coverage, meaning a coverage plan that is offered and generally available to State employees in the state. (Section 2103(b)(2))

6.1.1.2.

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.)

Guidance: Check box below if the benchmark benefit package to be offered by the State is offered by a health maintenance organization (as defined in Section 2791(b)(3) of the Public Health Services Act) and has the largest insured commercial, non-Medicaid enrollment of covered lives of such coverage plans offered by an HMO in the state. (Section 2103(b)(3) (42 CFR 457.420(c)))

6.1.1.3.

HMO with largest insured commercial enrollment (Section 2103(b)(3))

Effective Date: October 1, 2020

Approval Date: (If checked, identify the plan and attach a copy of the benefits description.)

Guidance: States choosing Benchmark-equivalent coverage must check the box below and ensure that the coverage meets the following requirements:  the coverage includes benefits for items and services within each of the categories of basic services described in 42 CFR 457.430: • dental services • inpatient and outpatient hospital services, • physicians’ services, • surgical and medical services, • laboratory and x-ray services, • well-baby and well-child care, including age-appropriate immunizations, and • emergency services;  the coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages (FEHBP-equivalent coverage, State employee coverage, or coverage offered through an HMO coverage plan that has the largest insured commercial enrollment in the state); and  the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the additional categories in such package, if offered, as described in 42 CFR 457.430: • coverage of prescription drugs, • mental health services, • vision services and • hearing services.

If 6.1.2. is checked, a signed actuarial memorandum must be attached. The actuary who prepares the opinion must select and specify the standardized set and population to be used under paragraphs (b)(3) and (b)(4) of 42 CFR 457.431. The State must provide sufficient detail to explain the basis of the methodologies used to estimate the actuarial value or, if requested by CMS, to replicate the State results.

The actuarial report must be prepared by an individual who is a member of the American Academy of Actuaries. This report must be prepared in accordance with the principles and standards of the American Academy of Actuaries. In preparing the report, the actuary must use generally accepted actuarial principles and methodologies, use a standardized set of utilization and price factors, use a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan, apply the same principles and factors in comparing the value of different coverage (or categories of services), without taking into account

Effective Date: October 1, 2020

Approval Date: any differences in coverage based on the method of delivery or means of cost control or utilization used, and take into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage. (Section 2103(a)(2))

6.1.2.

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

Guidance: A State approved under the provision below, may modify its program from time to time so long as it continues to provide coverage at least equal to the lower of the actuarial value of the coverage under the program as of August 5, 1997, or one of the benchmark programs. If “existing comprehensive state- based coverage” is modified, an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997, or one of the benchmark plans must be attached. Also, the fiscal year 1996 State expenditures for “existing comprehensive state-based coverage” must be described in the space provided for all states. (Section 2103(a)(3))

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) This option is only applicable to New York, Florida, and Pennsylvania. Attach a description of the benefits package, administration, and date of enactment. If existing comprehensive State-based coverage is modified, provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997 or one of the benchmark plans. Describe the fiscal year 1996 State expenditures for existing comprehensive state-based coverage.

Guidance: Secretary-approved coverage refers to any other health benefits coverage deemed appropriate and acceptable by the Secretary upon application by a state. (Section 2103(a)(4)) (42 CFR 457.250)

6.1.4.

Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) Guidance: Section 1905(r) of the Act defines EPSDT to require coverage of (1) any medically necessary screening, and diagnostic services, including vision, hearing, and dental screening and diagnostic services, consistent with a periodicity schedule based on current and reasonable medical practice standards or the health needs of an individual child to determine if a suspected condition or illness exists; and (2) all services listed in section 1905(a) of the Act that are necessary to correct or ameliorate any defects and mental and physical illnesses or conditions discovered by the screening services, whether or not those services are

Effective Date: October 1, 2020

Approval Date: covered under the Medicaid state plan. Section 1902(a)(43) of the Act requires that the State (1) provide and arrange for all necessary services, including supportive services, such as transportation, needed to receive medical care included within the scope of the EPSDT benefit and (2) inform eligible beneficiaries about the services available under the EPSDT benefit.

If the coverage provided does not meet all of the statutory requirements for EPSDT contained in sections 1902(a)(43) and 1905(r) of the Act, do not check this box.

6.1.4.1.

Coverage of all benefits that are provided to children under the same as Medicaid State plan, including Early Periodic Screening Diagnosis and Treatment (EPSDT)

6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver

6.1.4.3.

Coverage that the State has extended to the entire Medicaid population

Guidance: Check below if the coverage offered includes benchmark coverage, as specified in 457.420, plus additional coverage. Under this option, the State must clearly demonstrate that the coverage it provides includes the same coverage as the benchmark package, and also describes the services that are being added to the benchmark package.

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage

6.1.4.5.

Coverage that is the same as defined by existing comprehensive state- based coverage applicable only New York, Pennsylvania, or Florida (under 457.440)

Guidance: Check below if the State is purchasing coverage through a group health plan, and intends to demonstrate that the group health plan is substantially equivalent to or greater than to coverage under one of the benchmark plans specified in 457.420, through use of a benefit-by- benefit comparison of the coverage. Provide a sample of the comparison format that will be used. Under this option, if coverage for any benefit does not meet or exceed the coverage for that benefit under the benchmark, the State must provide an actuarial analysis as described in 457.431 to determine actuarial equivalence.

6.1.4.6.

Coverage under a group health plan that is substantially equivalent to or

Effective Date: October 1, 2020

Approval Date: greater than benchmark coverage through a benefit by benefit comparison (Provide a sample of how the comparison will be done)

Guidance: Check below if the State elects to provide a source of coverage that is not described above. Describe the coverage that will be offered, including any benefit limitations or exclusions.

6.1.4.7.

Other (Describe)

Guidance: All forms of coverage that the State elects to provide to children in its plan must be checked. The State should also describe the scope, amount and duration of services covered under its plan, as well as any exclusions or limitations. States that choose to cover unborn children under the State plan should include a separate section 6.2 that specifies benefits for the unborn child population. (Section 2110(a)) (42CFR, 457.490)

If the state elects to cover the new option of targeted low income pregnant women, but chooses to provide a different benefit package for these pregnant women under the CHIP plan, the state must include a separate section 6.2 describing the benefit package for pregnant women. (Section 2112)

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

6.2.1.

Inpatient services (Section 2110(a)(1))

6.2.2.

Outpatient services (Section 2110(a)(2))

6.2.3.

Physician services (Section 2110(a)(3))

6.2.4.

Surgical services (Section 2110(a)(4))

6.2.5.

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

6.2.6.

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

Effective Date: October 1, 2020

Approval Date: 6.2.7.

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

6.2.8.

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

6.2.9.

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

6.2.10.

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

6.2.11.

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

Guidance: Home and community based services may include supportive services such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home.

6.2.12.

Home and community-based health care services (Section 2110(a)(14))

Guidance: Nursing services may include nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services in a home, school or other setting.

6.2.13.

Nursing care services (Section 2110(a)(15))

6.2.14.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16)

6.2.15.

Dental services (Section 2110(a)(17)) States updating their dental benefits must complete 6.2-DC (CHIPRA # 7, SHO # #09-012 issued October 7, 2009)

6.2.16.

Vision screenings and services (Section 2110(a)(24))

6.2.17.

Hearing screenings and services (Section 2110(a)(24))

6.2.18.

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

Effective Date: October 1, 2020

Approval Date:

6.2.19.

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

6.2.20.

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

6.2.21.

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

Guidance: See guidance for section 6.1.4.1 for a guidance on the statutory requirements for EPSDT under sections 1905(r) and 1902(a)(43) of the Act. If the benefit being provided does not meet the EPSDT statutory requirements, do not check this box.

6.2.22.

EPSDT consistent with requirements of sections 1905(r) and 1902(a)(43) of the Act

6.2.22.1 The state assures that any limitations applied to the amount, duration, and scope of benefits described in Sections 6.2 and 6.3- BH of the CHIP state plan can be exceeded as medically necessary.

Guidance: Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or rehabilitative service may be provided, whether in a facility, home, school, or other setting, if recognized by State law and only if the service is: 1) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as prescribed by State law; 2) performed under the general supervision or at the direction of a physician; or 3) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

6.2.23.

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

6.2.24.

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

6.2.25.

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

Guidance: Enabling services, such as transportation, translation, and outreach services, may be offered only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.

Effective Date: October 1, 2020

Approval Date: 6.2.26.

Enabling services (such as transportation, translation, and outreach services) (Section 2110(a)(27))

6.2.27.

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

6.2-BH Behavioral Health Coverage Section 2103(c)(5) requires that states provide coverage to prevent, diagnose, and treat a broad range of mental health and substance use disorders in a culturally and linguistically appropriate manner for all CHIP enrollees, including pregnant women and unborn children.

Guidance: Please attach a copy of the state’s periodicity schedule. For pregnancy-related coverage, please describe the recommendations being followed for those services.

6.2.1- BH Periodicity Schedule The state has adopted the following periodicity schedule for behavioral health screenings and assessments. Please specify any differences between any covered CHIP populations:

State-developed schedule American Academy of Pediatrics/ Bright Futures Other Nationally recognized periodicity schedule (please specify: ) Other (please describe:)

6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i))

6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards

Effective Date: October 1, 2020

Approval Date: are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard.

International Classification of Disease (ICD) ICD-10-CM Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines (Describe: ) Other (Describe: ) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits?

Yes No Guidance: If the State does not provide any mental health or substance use disorder benefits, the mental health parity requirements do not apply ((42 CFR 457.496(f)(1)). Continue on to Section 6.3.

6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act) provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act.

6.2.2.1- MHPAEA Does the State child health plan provide coverage of EPSDT? The State must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements, as indicated in section 6.2.26 of the State child health plan in order to answer “yes.”

Yes No Guidance: If the State child health plan does not provide EPSDT consistent with Medicaid statutory requirements at sections 1902(a)(43) and 1905(r) of the Act, please go to Section 6.2.3- MHPAEA to complete the required parity analysis of the State child health plan.

If the state does provide EPSDT benefits consistent with Medicaid requirements, please continue this section to demonstrate compliance with the statutory requirements of section 2103(c)(6)(B) of the Act and the mental health parity regulations of 42 CFR 457.496(b) related to deemed

Effective Date: October 1, 2020

Approval Date: compliance. Please provide supporting documentation, such as contract language, provider manuals, and/or member handbooks describing the state’s provision of EPSDT.

6.2.2.2- MHPAEA EPSDT benefits are provided to the following:

All children covered under the State child health plan. A subset of children covered under the State child health plan. Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements. Guidance: If only a subset of children are provided EPSDT benefits under the State child health plan, 42 CFR 457.496(b)(3) limits deemed compliance to those children only and Section 6.2.3- MHPAEA must be completed as well as the required parity analysis for the other children.

6.2.2.3- MHPAEA To be deemed compliant with the MHPAEA parity requirements, States must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act (42 CFR 457.496(b)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan:

All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions. (Section 1905(r))

All diagnostic services described in 1905(a) of the Act are provided as needed to diagnose suspected conditions or illnesses discovered through screening services, whether or not those services are covered under the Medicaid state plan. (Section 1905(r))

All items and services described in section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan. (Section 1905(r)(5))

Effective Date: October 1, 2020

Approval Date: Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness. (Section 1905(r)(5))

Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness. (Section 1905(r)(5))

EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis. (Section 1905(r)(5))

The provision of all requested EPSDT screening services, as well as any corrective treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1902(a)(43))

All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A)) Guidance: For states seeking deemed compliance for their entire State child health plan population, please continue to Section 6.3. If not all of the covered populations are offered EPSDT, the State must conduct a parity analysis of the benefit packages provided to those populations. Please continue to 6.2.3- MHPAEA.

Mental Health Parity Analysis Requirements for States Not Providing EPSDT to All Covered Populations

Guidance: The State must complete a parity analysis for each population under the State child health plan that is not provided the EPSDT benefit consistent with the requirements 42 CFR 457.496(b). If the State provides benefits or limitations that vary within the child or pregnant woman populations, states should perform a parity analysis for each of the benefit packages. For example, if different financial requirements are applied according to a beneficiary’s income, a separate parity analysis is needed for the benefit package provided at each income level.

Please ensure that changes made to benefit limitations under the State child health plan as a

Effective Date: October 1, 2020

Approval Date: result of the parity analysis are also made in Section 6.2.

6.2.3- MHPAEA In order to conduct the parity analysis, the State must place all medical/surgical and mental health and substance use disorder benefits covered under the State child health plan into one of four classifications: Inpatient, outpatient, emergency care, and prescription drugs. (42 CFR 457.496(d)(2)(ii); 42 CFR 457.496(d)(3)(ii)(B))

6.2.3.1 MHPAEA Please describe below the standard(s) used to place covered benefits into one of the four classifications.

The final regulations specify that requirements for FRs and treatment limitations apply by benefit classification. Kid Care CHIP benefits were classified and mapped into four categories, as directed by the CMS Parity Toolkit. The following definitions were used to determine benefit classifications: Inpatient: Treatment as a registered bed patient in a hospital or facility other provider and for whom a room and board charge is made. Outpatient: All covered services or supplies not included in inpatient, emergency care, or prescription drug categories. Prescription Drugs: Medications that have been approved or regulated by the Food and Drug Administration that can, under federal and state law, be dispensed only pursuant to a Prescription Drug order from a licensed, certified, or otherwise legally authorized prescriber. Emergency Care: All covered emergency services or items (including medications) provided in an emergency department (ED) or emergency room (ER) setting in an OP hospital setting. 6.2.3.1.1 MHPAEA The State assures that:

The State has classified all benefits covered under the State plan into one of the four classifications. The same reasonable standards are used for determining the classification for a mental health or substance use disorder benefit as are used for determining the classification of medical/surgical benefits. 6.2.3.1.2- MHPAEA Does the State use sub-classifications to distinguish between office visits and other outpatient services?

Yes

Effective Date: October 1, 2020

Approval Date: No

6.2.3.1.2.1- MHPAEA If the State uses sub-classifications to distinguish between outpatient office visits and other outpatient services, the State assures the following:

The sub-classifications are only used to distinguish office visits from other outpatient items and services, and are not used to distinguish between similar services on other bases (ex: generalist vs. specialist visits). Guidance: For purposes of this section, any reference to “classification(s)” includes sub-classification(s) in states using sub- classifications to distinguish between outpatient office visits from other outpatient services.

6.2.3.2 MHPAEA The State assures that:

Mental health/ substance use disorder benefits are provided in all classifications in which medical/surgical benefits are provided under the State child health plan. Guidance: States are not required to cover mental health or substance use disorder benefits (42 CFR 457.496(f)(2)). However if a state does provide any mental health or substance use disorder benefits, those mental health or substance use disorder benefits must be provided in all the same classifications in which medical/surgical benefits are covered under the State child health plan (42 CFR 457.496(d)(2)(ii).

Annual and Aggregate Lifetime Dollar Limits

6.2.4- MHPAEA A State that provides both medical/surgical benefits and mental health and/or substance use disorder benefits must comply with parity requirements related to annual and aggregate lifetime dollar limits for benefits covered under the State child health plan. (42 CFR 457.496(c))

6.2.4.1- MHPAEA Please indicate whether the State applies an aggregate lifetime dollar limit and/or an annual dollar limit on any mental health or substance abuse disorder benefits covered under the State child health plan.

Aggregate lifetime dollar limit is applied Aggregate annual dollar limit is applied No dollar limit is applied

Effective Date: October 1, 2020

Approval Date: Guidance: A monetary coverage limit that applies to all CHIP services provided under the State child health plan is not subject to parity requirements.

If there are no aggregate lifetime or annual dollar limits on any mental health or substance use disorder benefits, please go to section 6.2.5- MHPAEA.

6.2.4.2- MHPAEA Are there any medical/surgical benefits covered under the State child health plan that have either an aggregate lifetime dollar limit or an annual dollar limit? If yes, please specify what type of limits apply.

Yes (Type(s) of limit: No Guidance: If no aggregate lifetime dollar limit is applied to medical/ surgical benefits, the State may not impose an aggregate lifetime dollar limit on any mental health or substance use disorder benefits. If no aggregate annual dollar limit is applied to medical/surgical benefits, the State may not impose an aggregate annual dollar limit on any mental health or substance use disorder benefits. (42 CFR 457.496(c)(1))

6.2.4.3 – MHPAEA. States applying an aggregate lifetime or annual dollar limit on medical/surgical benefits and mental health or substance use disorder benefits must determine whether the portion of the medical/surgical benefits to which the limit applies is less than one- third, at least one-third but less than two-thirds, or at least two-thirds of all medical/surgical benefits covered under the State plan (42 CFR 457.496(c)). The portion of medical/surgical benefits subject to the limit is based on the dollar amount expected to be paid for all medical/surgical benefits under the State plan for the State plan year or portion of the plan year after a change in benefits that affects the applicability of the aggregate lifetime or annual dollar limits. (42 CFR 457.496(c)(3))

The State assures that it has developed a reasonable methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable. Guidance: Please include the state’s methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit and the results as an attachment to the State child health plan.

6.2.4.3.1- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to a lifetime dollar limit:

Effective Date: October 1, 2020

Approval Date: Less than 1/3 At least 1/3 and less than 2/3 At least 2/3

6.2.4.3.2- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to an annual dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3 Guidance: If an aggregate lifetime limit is applied to less than one-third of all medical/surgical benefits, the State may not impose an aggregate lifetime limit on any mental health or substance use disorder benefits. If an annual dollar limit is applied to less than one-third of all medical surgical benefits, the State may not impose an annual dollar limit on any mental health or substance use disorder benefits (42 CFR 457.496(c)(1)). Skip to section 6.2.5-MHPAEA.

If the State applies an aggregate lifetime or annual dollar limit to at least one-third of all medical/surgical benefits, please continue below to provide the assurances related to the determination of the portion of total costs for medical/surgical benefits that are subject to either an annual or lifetime limit.

6.2.4.3.2.1- MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least 1/3 and less than 2/3 of all medical/surgical benefits, the State assures the following (42 CFR 457.496(c)(4)(i)(B)); (42 CFR 457.496(c)(4)(ii)):

The State applies an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no more restrictive than an average limit calculated for medical/surgical benefits. Guidance: The state’s methodology for calculating the average limit for medical/surgical benefits must be consistent with 42 CFR 457.496(c)(4)(i)(B) and 42 CFR 457.496(c)(4)(ii). Please include the state’s methodology and

Effective Date: October 1, 2020

Approval Date: results as an attachment to the State child health plan.

6.2.4.3.2.2- MHPAEA If at least 2/3 of all medical/surgical benefits are subject to an annual or lifetime limit, the State assures either of the following (42 CFR 457.496(c)(2)(i)); (42 CFR 457.496(c)(2)(ii)):

The aggregate lifetime or annual dollar limit is applied to both medical/surgical benefits and mental health and substance use disorder benefits in a manner that does not distinguish between medical/surgical benefits and mental health and substance use disorder benefits; or The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefits is no more restrictive than the aggregate lifetime or annual dollar limit on medical/surgical benefits. Quantitative Treatment Limitations

6.2.5- MHPAEA Does the State apply quantitative treatment limitations (QTLs) on any mental health or substance use disorder benefits in any classification of benefits? If yes, specify the classification(s) of benefits in which the State applies one or more QTLs on any mental health or substance use disorder benefits.

Yes (Specify: ) No Guidance: If the state does not apply any type of QTLs on any mental health or substance use disorder benefits in any classification, the state meets parity requirements for QTLs and should continue to Section 6.2.6 - MHPAEA. If the state does apply QTLs to any mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue.

6.2.5.1- MHPAEA Does the State apply any type of QTL on any medical/surgical benefits?

Yes No Guidance: If the State does not apply QTLs on any medical/surgical benefits, the State may not impose quantitative treatment limitations on mental health or substance use disorder benefits, please go to Section 6.2.6- MHPAEA related to non-quantitative treatment limitations.

Effective Date: October 1, 2020

Approval Date: 6.2.5.2- MHPAEA Within each classification of benefits in which the State applies a type of QTL on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the classification which are subject to the limitation. More specifically, the State must determine the ratio of (a) the dollar amount of all payments expected to be paid under the State plan for medical and surgical benefits within a classification which are subject to the type of quantitative treatment limitation for the plan year (or portion of the plan year after a mid-year change affecting the applicability of a type of quantitative treatment limitation to any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all medical and surgical benefits within the classification for the plan year. For purposes of this paragraph, all payments expected to be paid under the State plan includes payments expected to be made directly by the State and payments which are expected to be made by MCEs contracting with the State. (42 CFR 457.496(d)(3)(i)(C))

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above for each classification within which the State applies QTLs to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) Guidance: Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.5.3- MHPAEA For each type of QTL applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of QTL to “substantially all” (defined as at least two-thirds) of the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of QTL to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose that type of QTL on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

6.2.5.3.1- MHPAEA For each type of QTL applied to mental health or substance use disorder benefits, the State must determine the predominant level of that type which is applied to medical/surgical benefits in the classification. The “predominant level” of a type of QTL in a classification is the level (or least restrictive of a combination of levels) that applies to more than one-half of the medical/surgical benefits in that classification, as described in 42 CFR 457.496(d)(3)(i)(B). The portion of medical/surgical benefits in a classification to which a given level of a QTL type is applied is based on the dollar amount of payments expected to be paid for medical/surgical benefits subject to that level as compared to all medical/surgical

Effective Date: October 1, 2020

Approval Date: benefits in the classification, as described in 42 CFR 457.496(d)(3)(i)(C). For each type of quantitative treatment limitation applied to mental health or substance use disorder benefits, the State assures:

The same reasonable methodology applied in determining the dollar amounts used to determine whether substantially all medical/surgical benefits within a classification are subject to a type of quantitative treatment limitation also is applied in determining the dollar amounts used to determine the predominant level of a type of quantitative treatment limitation applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of quantitative treatment limitation applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of QTL that exceeds the one- half threshold, the State may combine levels within a type of QTL such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

Non-Quantitative Treatment Limitations

6.2.6- MHPAEA The State may utilize non-quantitative treatment limitations (NQTLs) for mental health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all the mental health parity requirements. (42 CFR 457.496(d)(4)); (42 CFR 457.496(d)(5)) 6.2.6.1 – MHPAEA If the State imposes any NQTLs, complete this subsection. If the State does not impose NQTLs, please go to Section 6.2.7-MHPAEA.

The State assures that the processes, strategies, evidentiary standards or other factors used in the application of any NQTL to mental health or substance use disorder benefits are no more stringent than the processes, strategies, evidentiary standards or other factors used in the application of NQTLs to medical/surgical benefits within the same classification. Guidance: Examples of NQTLs include medical management standards to limit or exclude benefits based on medical necessity, restrictions based on geographic location, provider specialty, or other criteria to limit the scope or duration of benefits and provider network design (ex: preferred providers vs. participating providers). Additional examples of possible NQTLs are provided in 42 CFR

Effective Date: October 1, 2020

Approval Date: 457.496(d)(4)(ii). States will need to provide a summary of its NQTL analysis, as well as supporting documentation as requested.

6.2.6.2 – MHPAEA The State or MCE contracting with the State must comply with parity if they provide coverage of medical or surgical benefits furnished by out-of-network providers.

6.2.6.2.1- MHPAEA Does the State or MCE contracting with the State provide

coverage of medical or surgical benefits provided by out-of-network providers?

Yes No Guidance: The State can answer no if the State or MCE only provides out of network services in specific circumstances, such as emergency care, or when the network is unable to provide a necessary service covered under the contract.

6.2.6.2.2- MHPAEA If yes, the State must provide access to out-of-network providers for mental health or substance use disorder benefits. Please assure the following:

The State attests that when determining access to out-of-network providers within a benefit classification, the processes, strategies, evidentiary standards, or other factors used to determine access to those providers for mental health/ substance use disorder benefits are comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors used to determine access for out- of-network providers for medical/surgical benefits. Availability of Plan Information 6.2.7- MHPAEA The State must provide beneficiaries, potential enrollees, and providers with information related to medical necessity criteria and denials of payment or reimbursement for mental health or substance use disorder services (42 CFR 457.496(e)) in addition to existing notice requirements at 42 CFR 457.1180.

6.2.7.1- MHPAEA Medical necessity criteria determinations must be made available to any current or potential enrollee or contracting provider, upon request. The state attests that the following entities provide this information:

State Managed Care entities Both

Effective Date: October 1, 2020

Approval Date: Other

Guidance: If other is selected, please specify the entity.

6.2.7.2- MHPAEA Reason for any denial for reimbursement or payment for

mental health or substance use disorder benefits must be made available to the

enrollee by the health plan or the State. The state attests that the following

entities provide denial information:

State Managed Care entities Both

Other

Guidance: If other is selected, please specify the entity. 6.3. The State assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1.

The State shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.

The State contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.6.2. (formerly 6.4.2) of the template). Pre- existing medical conditions are permitted to the extent allowed by HIPAA/ERISA. (Formerly 8.6.) (Section 2103(f)) Describe:

Guidance: States may request two additional purchase options in Title XXI: cost effective coverage through a community-based health delivery system and for the purchase of family coverage. (Section 2105(c)(2) and (3)) (457.1005 and 457.1010)

6.3- BH Covered Benefits Please check off the behavioral health services that are provided to the state’s CHIP populations, and provide a description of the amount, duration, and scope of each benefit. For each benefit, please also indicate whether the benefit is available for mental health and/or substance use disorders. If there are differences in benefits based on the population or type of condition being treated, please specify those differences.

If EPSDT is provided, as described at Section 6.2.22 and 6.2.22.1, the state should only check off the applicable benefits. It does not have to provide additional information regarding the amount, duration, and scope of each covered behavioral health benefit.

Effective Date: October 1, 2020

Approval Date: Guidance: Please include a description of the services provided in addition to the behavioral health screenings and assessments described in the assurance below at 6.3.1.1-BH.

6.3.1- BH Behavioral health screenings and assessments. (Section 2103(c)(6)(A))

6.3.1.1- BH The state assures that all developmental and behavioral health recommendations outlined in the AAP Bright Futures periodicity schedule and United States Public Preventive Services Task Force (USPSTF) recommendations graded as A and B are covered as a part of the CHIP benefit package, as appropriate for the covered populations.

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools in primary care practice, providing education, training, and technical resources, and covering the costs of administering or purchasing the tools.

6.3.1.2- BH The state assures that it will implement a strategy to facilitate the use of age-appropriate validated behavioral health screening tools in primary care settings. Please describe how the state will facilitate the use of validated screening tools.

6.3.2- BH Outpatient services (Sections 2110(a)(11) and 2110(a)(19))

Guidance: Psychosocial treatment includes services such as psychotherapy, group therapy, family therapy and other types of counseling services.

6.3.2.1- BH Psychosocial treatment Provided for: Mental Health Substance Use Disorder

6.3.2.2- BH Tobacco cessation Provided for: Substance Use Disorder

Guidance: In order to provide a benefit package consistent with section 2103(c)(5) of the Act, MAT benefits are required for the treatment of opioid use disorders. However, if the state provides MAT for other SUD conditions, please include a description of those benefits below at section 6.3.2.3- BH.

6.3.2.3- BH Medication Assisted Treatment Provided for: Substance Use Disorder

6.3.2.3.1- BH Opioid Use Disorder

6.3.2.3.2- BH Alcohol Use Disorder

Effective Date: October 1, 2020

Approval Date: 6.3.2.3.3- BH Other

6.3.2.4- BH Peer Support Provided for: Mental Health Substance Use Disorder

6.3.2.5- BH Caregiver Support Provided for: Mental Health Substance Use Disorder

6.3.2.6- BH Respite Care Provided for: Mental Health Substance Use Disorder

6.3.2.7- BH Intensive in-home services Provided for: Mental Health Substance Use Disorder

6.3.2.8- BH Intensive outpatient Provided for: Mental Health Substance Use Disorder

6.3.2.9- BH Psychosocial rehabilitation Provided for: Mental Health Substance Use Disorder

Guidance: If the state considers day treatment and partial hospitalization to be the same benefit, please indicate that in the benefit description. If there are differences between these benefits, such as the staffing or intensity of the setting, please specify those in the description of the benefit’s amount, duration, and scope.

6.3.3- BH Day Treatment Provided for: Mental Health Substance Use Disorder

6.3.3.1- BH Partial Hospitalization Provided for: Mental Health Substance Use Disorder

6.3.4- BH Inpatient services, including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Sections 2110(a)(10) and 2110(a)(18)) Provided for: Mental Health Substance Use Disorder

Guidance: If applicable, please clarify any differences within the residential treatment benefit (e.g. intensity of services, provider types, or settings in which the residential treatment services are provided).

6.3.4.1- BH Residential Treatment Provided for: Mental Health Substance Use Disorder

6.3.4.2- BH Detoxification

Effective Date: October 1, 2020

Approval Date: Provided for: Substance Use Disorder

Guidance: Crisis intervention and stabilization could include services such as mobile crisis, or short term residential or other facility based services in order to avoid inpatient hospitalization.

6.3.5- BH Emergency services Provided for: Mental Health Substance Use Disorder

6.3.5.1- BH Crisis Intervention and Stabilization Provided for: Mental Health Substance Use Disorder

6.3.6- BH Continuing care services Provided for: Mental Health Substance Use Disorder

6.3.7- BH Care Coordination Provided for: Mental Health Substance Use Disorder

6.3.7.1- BH Intensive wraparound Provided for: Mental Health Substance Use Disorder

6.3.7.2- BH Care transition services Provided for: Mental Health Substance Use Disorder

6.3.8- BH Case Management Provided for: Mental Health Substance Use Disorder

6.3.9- BH Other Provided for: Mental Health Substance Use Disorder

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

6.4.1.

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

Effective Date: October 1, 2020

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

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

Guidance: Check below if the State is requesting to provide cost-effective coverage through a community-based health delivery system. This allows the State to waive the 10 percent limitation on expenditures not used for Medicaid or health insurance assistance if coverage provided to targeted low-income children through such expenditures meets the requirements of Section 2103; the cost of such coverage is not greater, on an average per child basis, than the cost of coverage that would otherwise be provided under Section 2103; and such coverage is provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under Section 330 of the Public Health Services Act or with hospitals such as those that receive disproportionate share payment adjustments under Section 1886(c)(5)(F) or 1923.

If the cost-effective alternative waiver is requested, the State must demonstrate that payments in excess of the 10 percent limitation will be used for other child health assistance for targeted low-income children; expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); expenditures for outreach activities as provided in Section 2102(c)(1) under the plan; and other reasonable costs incurred by the State to administer the plan. (42CFR, 457.1005(a))

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

Effective Date: October 1, 2020

Approval Date: Guidance: Check 6.4.2.if the State is requesting to purchase family coverage. Any State requesting to purchase such coverage will need to include information that establishes to the Secretary’s satisfaction that: 1) when compared to the amount of money that would have been paid to cover only the children involved with a comparable package, the purchase of family coverage is cost effective; and 2) the purchase of family coverage is not a substitution for coverage already being provided to the child. (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.

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

6.4.2.1. Purchase of family coverage is cost-effective. The State’s cost of purchasing family coverage, including administrative expenditures, that includes coverage for the targeted low-income children involved or the family involved (as applicable) under premium assistance programs must not be greater than the cost of obtaining coverage under the State plan for all eligible targeted low-income children or families involved; and (2) The State may base its demonstration of cost effectiveness on an assessment of the cost of coverage, including administrative costs, for children or families under premium assistance programs to the cost of other CHIP coverage for these children or families, done on a case- by-case basis, or on the cost of premium assisted coverage in the aggregate.

6.4.2.2. The State assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b))

6.4.2.3. The State assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

6.4.3-PA: Additional State Options for Providing Premium Assistance (CHIPRA # 13, SHO # 10-002 issued February, 2, 2010) A State may elect to offer a premium assistance subsidy for qualified employer-sponsored coverage, as defined in Section 2105(c)(10)(B), to all targeted low-income children who are eligible for child health assistance under the plan and have access to such coverage. No subsidy shall be provided to a targeted low-income child (or the child’s parent) unless the child voluntarily elects to receive such a subsidy. (Section 2105(c)(10)(A)). Please remember to update section 9.10 when electing this option. Does the State provide this option to targeted low-income children?

Effective Date: October 1, 2020

Approval Date:

Yes

No

6.4.3.1-PA Qualified Employer-Sponsored Coverage and Premium Assistance Subsidy

6.4.3.1.1-PA Provide an assurance that the qualified employer-sponsored insurance meets the definition of qualified employer-sponsored coverage as defined in Section 2105(c)(10)(B), and that the premium assistance subsidy meets the definition of premium assistance subsidy as defined in 2105(c)(10)(C).

6.4.3.1.2-PA Describe whether the State is providing the premium assistance subsidy as reimbursement to an employee or for out-of-pocket expenditures or directly to the employee’s employer.

6.4.3.2-PA: Supplemental Coverage for Benefits and Cost Sharing Protections Provided under the Child Health Plan.

6.4.3.2.1-PA If the State is providing premium assistance for qualified employer-sponsored coverage, as defined in Section 2105(c)(10)(E)(i), provide an assurance that the State is providing for each targeted low-income child enrolled in such coverage, supplemental coverage consisting of all items or services that are not covered or are only partially covered, under the qualified employer-sponsored coverage consistent with 2103(a) and cost sharing protections consistent with Section 2103(e).

6.4.3.2.2-PA Describe whether these benefits are being provided through the employer or by the State providing wraparound benefits.

6.4.3.2.3-PA If the State is providing premium assistance for benchmark or benchmark-equivalent coverage, the State ensures that such group health plans or health insurance coverage offered through an employer will be certified by an actuary as coverage that is equivalent to a benchmark benefit package described in Section 2103(b) or benchmark equivalent coverage that meets the requirements of Section 2103(a)(2).

6.4.3.3-PA: Application of Waiting Period Imposed Under State Plan: States are required to apply the same waiting period to premium assistance as is applied to direct coverage for children under their CHIP State plan, as specified in Section 2105(c)(10)(F).

6.4.3.3.1-PA Provide an assurance that the waiting period for children in premium assistance is the same as for those children in direct coverage (if State

Effective Date: October 1, 2020

Approval Date: has a waiting period in place for children in direct CHIP coverage).

6.4.3.4-PA: Opt-Out and Outreach, Education, and Enrollment Assistance

6.4.3.4.1-PA Describe the State’s process for ensuring parents are permitted to disenroll their child from qualified employer-sponsored coverage and to enroll in CHIP effective on the first day of any month for which the child is eligible for such assistance and in a manner that ensures continuity of coverage for the child (Section 2105(c)(10)(G)).

6.4.3.4.2-PA Describe the State’s outreach, education, and enrollment efforts related to premium assistance programs, as required under Section 2102(c)(3). How does the State inform families of the availability of premium assistance, and assist them in obtaining such subsidies? What are the specific significant resources the State intends to apply to educate employers about the availability of premium assistance subsidies under the State child health plan? (Section 2102(c))

6.4.3.5-PA Purchasing Pool- A State may establish an employer-family premium assistance purchasing pool and may provide a premium assistance subsidy for enrollment in coverage made available through this pool (Section 2105(c)(10)(I)). Does the State provide this option?

Yes

No

6.6.3.5.1-PA Describe the plan to establish an employer-family premium assistance purchasing pool.

6.6.3.5.2-PA Provide an assurance that employers who are eligible to participate: 1) have less than 250 employees; 2) have at least one employee who is a pregnant woman eligible for CHIP or a member of a family that has at least one child eligible under the State’s CHIP plan.

6.6.3.5.3-PA Provide an assurance that the State will not claim for any administrative expenditures attributable to the establishment or operation of such a pool except to the extent such payment would otherwise be permitted under this title.

6.4.3.6-PA Notice of Availability of Premium Assistance- Describe the procedures that assure that if a State provides premium assistance subsidies under this Section, it must: 1) provide as part of the application and enrollment process, information describing the availability of premium assistance and how to elect to obtain a subsidy; and 2) establish other procedures to ensure that parents are fully

Effective Date: October 1, 2020

Approval Date: informed of the choices for child health assistance or through the receipt of premium assistance subsidies (Section 2105(c)(10)(K)).

6.4.3.6.1-PA Provide an assurance that the State includes information about premium assistance on the CHIP application or enrollment form.

6.4- BH Assessment Tools

6.4.1- BH Please specify or describe all of the tool(s) required by the state and/or each managed care entity:

ASAM Criteria (American Society Addiction Medicine) Mental Health Substance Use Disorders

InterQual Mental Health Substance Use Disorders

MCG Care Guidelines Mental Health Substance Use Disorders

CALOCUS/LOCUS (Child and Adolescent Level of Care Utilization System)

Mental Health Substance Use Disorders

CASII (Child and Adolescent Service Intensity Instrument) Mental Health Substance Use Disorders

CANS (Child and Adolescent Needs and Strengths) Mental Health Substance Use Disorders

State-specific criteria (e.g. state law or policies) (please describe) Mental Health Substance Use Disorders

Plan-specific criteria (please describe) Mental Health Substance Use Disorders

Other (please describe) Mental Health Substance Use Disorders

No specific criteria or tools are required Mental Health Substance Use Disorders

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools to determine possible treatments or plans of care, providing

Effective Date: October 1, 2020

Approval Date: education, training, and technical resources, and covering the costs of administering or purchasing the assessment tools.

6.4.2- BH Please describe the state’s strategy to facilitate the use of validated assessment tools for the treatment of behavioral health conditions.

Effective Date: October 1, 2020

Approval Date: Section 7. Quality and Appropriateness of Care

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

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

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

Quality standards 7.1.2.

Performance measurement 7.1.3.

Information strategies 7.1.4.

Quality improvement strategies

7.1.2 Performance measurements

7.1.3 Information Strategy

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

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

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

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

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

Effective Date: October 1, 2020

Approval Date: Section 8. Cost-Sharing and Payment

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

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505) Indicate if this also applies for pregnant women. (CHIPRA #2, SHO # 09-006, issued May 11, 2009)

8.1.1.

Yes 8.1.2.

No, skip to question 8.8.

8.1.1-PW

Yes 8.1.2-PW

No, skip to question 8.8.

Guidance: It is important to note that for families below 150 percent of poverty, the same limitations on cost sharing that are under the Medicaid program apply. (These cost- sharing limitations have been set forth in Section 1916 of the Social Security Act, as implemented by regulations at 42 CFR 447.50 - 447.59). For families with incomes of 150 percent of poverty and above, cost sharing for all children in the family cannot exceed 5 percent of a family's income per year. Include a statement that no cost sharing will be charged for pregnancy-related services. (CHIPRA #2, SHO # 09-006, issued May 11, 2009) (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) and (c), 457.515(a) and (c))

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge by age and income (if applicable) and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) and (c), 457.515(a) and (c))

8.2.1.

Premiums:

8.2.2.

Deductibles:

8.2.3.

Coinsurance or copayments:

8.2.4.

Other:

8.2-DS

Supplemental Dental (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) For children enrolled in the dental-only supplemental coverage, describe the amount of cost-sharing, specifying any sliding scale based on income. Also describe how the State will track that the cost sharing does not exceed 5 percent of gross family income. The 5 percent of income calculation shall include all cost-sharing for health insurance

Effective Date: October 1, 2020

Approval Date: and dental insurance. (Section 2103(e)(1)(A)) (42 CFR 457.505(a), 457.510(b), and (c), 457.515(a) and (c), and 457.560(a)) Please update Sections 1.1-DS, 4.1-DS, 4.2- DS, 6.2-DS, and 9.10 when electing this option.

8.2.1-DS Premiums:

8.2.2-DS Deductibles:

8.2.3-DS Coinsurance or copayments:

8.2.4-DS Other:

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

Guidance: The State should be able to demonstrate upon request its rationale and justification regarding these assurances. This section also addresses limitations on payments for certain expenditures and requirements for maintenance of effort.

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

8.4.1.

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2.

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

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

8.4.1- MHPAEA There is no separate accumulation of cumulative financial requirements, as defined in 42 CFR 457.496(a), for mental health and substance abuse disorder benefits compared to medical/surgical benefits. (42 CFR 457.496(d)(3)(iii))

8.4.2- MHPAEA If applicable, any different levels of financial requirements that are applied to different tiers of prescription drugs are determined based on reasonable factors, regardless of whether a drug is generally prescribed for medical/surgical benefits or mental health/substance use disorder benefits. (42 CFR 457.496(d)(3)(ii)(A))

8.4.3- MHPAEA Cost sharing applied to benefits provided under the State child health plan will remain capped at five percent of the beneficiary’s income as required

Effective Date: October 1, 2020

Approval Date: by 42 CFR 457.560 (42 CFR 457.496(d)(3)(i)(D)).

8.4.4- MHPAEA Does the State apply financial requirements to any mental health or substance use disorder benefits? If yes, specify the classification(s) of benefits in which the State applies financial requirements on any mental health or substance use disorder benefits.

Yes (Specify: Wyoming CHIP applies a co-payment to all services, both medical/surgical and MH/SUD, as outlined in Section 8.) No Guidance: For the purposes of parity, financial requirements include deductibles, copayments, coinsurance, and out of pocket maximums; premiums are excluded from the definition. If the state does not apply financial requirements on any mental health or substance use disorder benefits, the state meets parity requirements for financial requirements. If the state does apply financial requirements to mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue below.

Please ensure that changes made to financial requirements under the State child health plan as a result of the parity analysis are also made in Section 8.2.

8.4.5- MHPAEA Does the State apply any type of financial requirements on any medical/surgical benefits?

Yes No Guidance: If the State does not apply financial requirements on any medical/surgical benefits, the State may not impose financial requirements on mental health or substance use disorder benefits.

8.4.6- MHPAEA Within each classification of benefits in which the State applies a type of financial requirement on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the class which are subject to the limitation.

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above (Section 6.2.5.2-MHPAEA) for each classification or within which the State applies financial requirements

Effective Date: October 1, 2020

Approval Date: to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) Guidance: Please include the state’s methodology and results of the parity analysis as an attachment to the State child health plan.

8.4.7- MHPAEA For each type of financial requirement applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of financial requirement to at least two-thirds (“substantially all”) of all the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of financial requirement to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose financial requirements on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

8.4.8- MHPAEA For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State must determine the predominant level (as defined in 42 CFR 457.496(d)(3)(i)(B)) of that type which is applied to medical/surgical benefits in the classification. For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State assures:

The same reasonable methodology applied in determining the dollar amounts used in determining whether substantially all medical/surgical benefits within a classification are subject to a type of financial requirement also is applied in determining the dollar amounts used to determine the predominant level of a type of financial requirement applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of financial requirement applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of financial requirement that exceeds the one-half threshold, the State may combine levels within a

Effective Date: October 1, 2020

Approval Date: type of financial requirement such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

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

8.6 Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

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

Guidance: Section 8.7.1 is based on Section 2101(a) of the Act provides that the purpose of title XXI is to provide funds to States to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner that is coordinated with other sources of health benefits coverage for children.

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

Guidance: Provide a description below of the State’s premium grace period process and how the State notifies families of their rights and responsibilities with respect to payment of premiums. (Section 2103(e)(3)(C))

8.7.1.1.

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

8.7.1.2.

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b))

8.7.1.3.

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

Effective Date: October 1, 2020

Approval Date:

8.7.1.4

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

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

8.8.1.

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

8.8.2.

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

8.8.3.

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

8.8.4.

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

8.8.5.

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

8.8.6.

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

Effective Date: October 1, 2020

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

Guidance: States should consider aligning its strategic objectives with those discussed in Section II of the CHIP Annual Report.

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

Strategic Objectives are listed in the following table.

Guidance: Goals should be measurable, quantifiable and convey a target the State is working towards.

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

Performance Goals are listed in the following table.

Guidance: The State should include data sources to be used to assess each performance goal. In addition, check all appropriate measures from 9.3.1 to 9.3.8 that the State will be utilizing to measure performance, even if doing so duplicates what the State has already discussed in Section 9.

It is acceptable for the State to include performance measures for population subgroups chosen by the State for special emphasis, such as racial or ethnic minorities, particular high-risk or hard to reach populations, children with special needs, etc.

HEDIS (Health Employer Data and Information Set) 2008 contains performance measures relevant to children and adolescents younger than 19. In addition, HEDIS 3.0 contains measures for the general population, for which breakouts by children’s age bands (e.g., ages < 1, 1-9, 10-19) are required. Full definitions, explanations of data sources, and other important guidance on the use of HEDIS measures can be found in the HEDIS 2008 manual published by the National Committee on Quality Assurance. So that State HEDIS results are consistent and comparable with national and regional data, states should check the HEDIS 2008 manual for detailed definitions of each measure, including definitions of the numerator and denominator to be used. For states that do not plan to offer managed care plans, HEDIS measures may also be able to be adapted to organizations of care other than managed care.

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

Effective Date: October 1, 2020

Approval Date: 457.710(d))

Performance measures are listed in the following table. The table provides a clear picture of the strategic objectives, performance goals, and performance measures and the data elements proposed to measure them. The strategic objectives may have more than one goal. Each goal has a performance measure and a corresponding set of measurable data elements which are depicted horizontally. As a first step in assessing progress in meeting the strategic objectives, evaluators will establish a baseline, or standard point of comparison, for each measure. In most cases, the baseline will be a snapshot of the performance measure at a point in time prior to implementation of the Kid Care CHIP. In areas where data is difficult to obtain, such as the number of uninsured children or health outcome indicators, all efforts will be used to gather and report as accurate information as possible.

Kid Care CHIP Strategic Objectives, Performance Goals and Measures, and Data Elements

Strategic Objective Performance Goals Performance Measures/Data Elements 1. Provide an application and enrollment process that is easy for targeted low-income families to understand and use. a) Increase the reapplication rate among MCHIP eligibles.

a) Track number of renewals sent out in the year and the number returned.

2. Decrease the number of children in Wyoming who are uninsured.

a) Decrease the proportion of uninsured children either at or below 200% FPL by 1% each year.

a) Utilize data from the Census Bureau

3. Ensure that children enrolled in M-CHIP receive timely and comprehensive preventive health care services.

Increase the percentage of low- income children with a regular source of care.

a). Encourage use of a Primary Care Provider through Health Plan policies and education.

a). Percent of enrolled children who seek care from their selected primary care provider.

Effective Date: October 1, 2020

Approval Date: 4. Ensure that there are a sufficient number of network providers in each county for M- CHIP participants. a). 60% of counties will have a sufficient network of providers so that participants in M-CHIP will have adequate access to covered services.

b). 60% of counties will have a sufficient network of dental providers so that participants in M-CHIP will have adequate access to covered services. a & b). A review of the networks in each county will be completed annually by the Department. 5. Decrease unnecessary use of emergency departments for non- emergency services

Reduce the number of emergency department visits for non-emergency services Rate of non-emergency ER visits per year for the M-CHIP population.

6. Ensure use of primary care providers through health plan policies and education At least 60% of children are utilizing a primary care provider Review data on number of children that have utilized a primary care provider. 7. Increase the number of children receiving well child visits.

a). At least 50 percent of children who turned 15 months old during the preceding year and were continuously enrolled in M- CHIP from 31 days of age, will have received at least four well- child visits with a primary care provider during their first 15 months of life.

b). At least 50 percent of three, four, five, or six year old children who were continuously enrolled in M- CHIP during the preceding year, will have received one or more well-care visits with a primary health care provider during the preceding year

a). Reports will be ran by the department and reviewed.

Effective Date: October 1, 2020

Approval Date: 8. Increase the number of children utilizing dental benefits At least 50 percent of five and six -year old children enrolled in Kid Care CHIP will have received dental services prior to kindergarten entry

At least 50 percent of Kid Care CHIP enrolled children seven to ten years will have received protective sealants on at least one occlusal surface of a permanent molar

Reports will be ran by the department and reviewed. 9. Implement a state-wide outreach and public awareness campaign regarding the importance of preventive and primary care and the availability of health care benefits through M-CHIP. a) Create Kid Care CHIP information materials targeted to potential eligibles, health care providers, and other professionals that have contact with families with children. b) Documentation of development and distribution of materials.

Check the applicable suggested performance measurements listed below that the State plans to use: (Section 2107(a)(4)) 9.3.1.

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

The reduction in the percentage of uninsured children. 9.3.3.

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

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

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

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

9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1.

Immunizations 9.3.7.2.

Well childcare 9.3.7.3.

Adolescent well visits

Effective Date: October 1, 2020

Approval Date: 9.3.7.4.

Satisfaction with care 9.3.7.5.

Mental health 9.3.7.6.

Dental care 9.3.7.7.

Other, list:

9.3.8.

Performance measures for special targeted populations.

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

Guidance: The State should include an assurance of compliance with the annual reporting requirements, including an assessment of reducing the number of low-income uninsured children. The State should also discuss any annual activities to be undertaken that relate to assessment and evaluation of the program.

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

The State assures it will comply with the annual assessment and evaluation required under Sections 10.1 and 10.2.

The state will on an annual basis assess and evaluate the operation and effectiveness of this plan and report all findings to CMS by January 1 of each year.

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

Guidance: The State should verify that they will participate in the collection and evaluation of data as new measures are developed or existing measures are revised as deemed necessary by CMS, the states, advocates, and other interested parties.

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

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

9.8.1.

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

Effective Date: October 1, 2020

Approval Date: 9.8.2.

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

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

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

Guidance: Section 9.9 can include discussion of community-based providers and consumer representatives in the design and implementation of the plan and the method for ensuring ongoing public involvement. Issues to address include a listing of public meetings or announcements made to the public concerning the development of the children's health insurance program or public forums used to discuss changes to the State plan.

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

During the 2020 legislative session, the CHIP was thoroughly discussed during the public hearings on House Bill 0120, which was introduced to allow CHIP from stand- alone (managed care) to expansion under Medicaid (fee-for-service). Any future changes concerning the operation of the CHIP will require legislative approval. In Wyoming, each introduced bill has at least one committee hearing, which is open to anyone who wishes to testify on the bill. After the committee hearing, bills must be voted on in at least one chamber by the legislature. This process provides the citizens of Wyoming with ample opportunity to provide input before final action is taken by the legislature.

In addition, the Department will provide an opportunity for public input whenever major changes in the state plan are finalized and before the plan is submitted for approval. Comments from all interested parties will be solicited either in writing or orally. These comments will be reviewed and considered prior to the submission of any substantial change to the state plan.

Ongoing input from the public will continue. Interim legislative committee meetings are open to any interested party who wishes to provide input about this program.

9.9.1. Describe the process used by the State to ensure interaction with Indian Tribes and organizations in the State on the development and implementation of the procedures required in 42 CFR 457.125. States should provide notice and consultation with Tribes on proposed pregnant women expansions. (Section 2107(c)) (42CFR 457.120(c))

Tribal consultation was sent via email on August 6, 2020, to these tribal organizations: IHS, Northern Arapaho, Eastern Shoshone, and Wind River Cares. No response was received as of the date of this SPA submission. If response is received after this date, the Wyoming Department of Health will address Tribal comments at that time.

Effective Date: October 1, 2020

Approval Date:

9.9.2. For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), describe how and when prior public notice was provided as required in 42 CFR 457.65(b) through (d).

The general public received notification of these changes on August 16, 2020, via newspaper publication.

9.9.3. Describe the State’s interaction, consultation, and coordination with any Indian tribes and organizations in the State regarding implementation of the Express Lane eligibility option.

Wyoming does not have Express Lane eligibility.

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

• Planned use of funds, including: • Projected amount to be spent on health services; • Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and • Assumptions on which the budget is based, including cost per child and expected enrollment. • Projected expenditures for the separate child health plan, including but not limited to expenditures for targeted low income children, the optional coverage of the unborn, lawfully residing eligibles, dental services, etc. • All cost sharing, benefit, payment, eligibility need to be reflected in the budget.

• Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. • Include a separate budget line to indicate the cost of providing coverage to pregnant women. • States must include a separate budget line item to indicate the cost of providing coverage to premium assistance children. • Include a separate budget line to indicate the cost of providing dental-only supplemental coverage. • Include a separate budget line to indicate the cost of implementing Express Lane Eligibility. • Provide a 1-year projected budget for all targeted low-income children covered under the state plan using the attached form. Additionally, provide the following: - Total 1-year cost of adding prenatal coverage - Estimate of unborn children covered in year 1

Effective Date: October 1, 2020

Approval Date:

CHIP Budget STATE: WYOMING FFY Budget Federal Fiscal Year 2021 State’s enhanced FMAP rate 65%

Benefit Costs

Insurance payments

Managed care

per member/per month rate

Fee for Service $9,850,700 Total Benefit Costs $9,850,700 (Offsetting beneficiary cost sharing payments)

Net Benefit Costs $9,850,700 Cost of Proposed SPA Changes – Benefit $9,850,700

Administration Costs

Personnel $243,140 General administration $179,453 Contractors/Brokers $271,236 Claims Processing $100,000 Outreach/marketing costs $5,408 Health Services Initiatives

Other

Total Administration Costs $799,237 10% Administrative Cap $1,094,522

Cost of Proposed SPA Changes $10,649,937

Federal Share $6,922459 State Share $3,727,478 Total Costs of Approved CHIP Plan $10,649,937

NOTE: Include the costs associated with the current SPA.

The Source of State Share Funds: State General Funds

Personnel Kid Care CHIP will have two positions dedicated to administering the program.

Supportive Services

Effective Date: October 1, 2020

Approval Date: General operations costs include equipment, travel, office supplies, and postage, printing, and telephone toll charges.

Effective Date: October 1, 2020

Approval Date: Section 10. Annual Reports and Evaluations

Guidance: The National Academy for State Health Policy (NASHP), CMS and the states developed framework for the annual report that states have the option to use to complete the required evaluation report. The framework recognizes the diversity in State approaches to implementing CHIP and provides consistency across states in the structure, content, and format of the evaluation report. Use of the framework and submission of this information will allow comparisons to be made between states and on a nationwide basis. The framework for the annual report can be obtained from NASHP’s website at http://www.nashp.org. Per the title XXI statute at Section 2108(a), states must submit reports by January 1st to be compliant with requirements.

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

10.1.1.

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

10.2.

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

10.3.

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

10.3-DC The State agrees to submit yearly the approved dental benefit package and to submit quarterly current and accurate information on enrolled dental providers in the State to the Health Resources and Services Administration for posting on the Insure Kids Now! Website. Please update Sections 6.2-DC and 9.10 when electing this option.

Effective Date: October 1, 2020

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

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

11.1.

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

11.2. The State assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a State under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) (The items below were moved from section 9.8. Previously 9.8.6. - 9.8.9.)

11.2.1.

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

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

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

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

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

Section 1128E (relating to the National health care fraud and abuse data

Effective Date: October 1, 2020

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

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

12.1. Eligibility and Enrollment Matters- Describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120. Describe any special processes and procedures that are unique to the applicant’s rights when the State is using the Express Lane option when determining eligibility.

Guidance: “Health services matters” refers to grievances relating to the provision of health care.

12.2. Health Services Matters- Describe the review process for health services matters that complies with 42 CFR 457.1120.

12.3. Premium Assistance Programs- If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, describe how the State will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

Effective Date: October 1, 2020

Approval Date: Key for Newly Incorporated Templates The newly incorporated templates are indicated with the following letters after the numerical section throughout the template.

• PC- Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • PW- Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • TC- Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • DC- Dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • DS- Supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • PA- Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • EL- Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • LR- Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010)

Effective Date: October 1, 2020

Approval Date:

CMS Regional Offices CMS Regional Offices States Associate Regional Administrator Regional Office Address Region 1- Boston Connecticut Massachuset ts Maine New Hampshire Rhode Island Vermont Richard R. McGreal richard.mcgreal@cms.hhs.gov John F. Kennedy Federal Bldg. Room 2275 Boston, MA 02203-0003 Region 2- New York New York Virgin Islands New Jersey Puerto Rico Michael Melendez michael.melendez@cms.hhs.gov 26 Federal Plaza Room 3811 New York, NY 10278-0063 Region 3- Philadelph ia Delaware District of Columbia Maryland Pennsylvania Virginia West Virginia Ted Gallagher ted.gallagher@cms.hhs.gov The Public Ledger Building 150 South Independence Mall West Suite 216 Philadelphia, PA 19106 Region 4- Atlanta Alabama Florida Georgia Kentucky Mississippi North Carolina South Carolina Tennessee Jackie Glaze jackie.glaze@cms.hhs.gov

Atlanta Federal Center 4th Floor 61 Forsyth Street, S.W. Suite 4T20 Atlanta, GA 30303-8909 Region 5- Chicago Illinois Indiana Michigan Minnesota Ohio Wisconsin Verlon Johnson verlon.johnson@cms.hhs.gov 233 North Michigan Avenue, Suite 600 Chicago, IL 60601 Region 6- Dallas Arkansas Louisiana New Mexico Oklahoma Texas Bill Brooks bill.brooks@cms.hhs.gov 1301 Young Street, 8th Floor Dallas, TX 75202 Region 7- Kansas City Iowa Kansas Missouri Nebraska

James G. Scott james.scott1@cms.hhs.gov Richard Bulling Federal Bldg. 601 East 12 Street, Room 235 Kansas City, MO 64106-2808 Region 8- Denver Colorado Montana North Dakota South Dakota Utah Wyoming Richard Allen richard.allen@cms.hhs.gov Federal Office Building, Room 522 1961 Stout Street Denver, CO 80294-3538 Region 9- San Francisco

Arizona California Hawaii Nevada American Samoa Guam Northern Mariana Islands Gloria Nagle gloria.nagle@cms.hhs.gov 90 Seventh Street Suite 5-300 San Francisco Federal Building San Francisco, CA 94103 Region 10- Seattle Idaho Washington Alaska Oregon Carol Peverly carol.peverly@cms.hhs.gov 2001 Sixth Avenue MS RX-43 Seattle, WA 98121

Effective Date: October 1, 2020

Approval Date: GLOSSARY Adapted directly from Sec. 2110. DEFINITIONS. CHILD HEALTH ASSISTANCE- For purposes of this title, the term ‘child health assistance’ means payment for part or all of the cost of health benefits coverage for targeted low-income children that includes any of the following (and includes, in the case described in Section 2105(a)(2)(A), payment for part or all of the cost of providing any of the following), as specified under the State plan: 1. Inpatient hospital services. 2. Outpatient hospital services. 3. Physician services. 4. Surgical services. 5. Clinic services (including health center services) and other ambulatory health care services. 6. Prescription drugs and biologicals and the administration of such drugs and biologicals, only if such drugs and biologicals are not furnished for the purpose of causing, or assisting in causing, the death, suicide, euthanasia, or mercy killing of a person. 7. Over-the-counter medications. 8. Laboratory and radiological services. 9. Prenatal care and prepregnancy family planning services and supplies. 10. Inpatient mental health services, other than services described in paragraph (18) but including services furnished in a State-operated mental hospital and including residential or other 24- hour therapeutically planned structured services. 11. Outpatient mental health services, other than services described in paragraph (19) but including services furnished in a State-operated mental hospital and including community- based services. 12. Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices). 13. Disposable medical supplies. 14. Home and community-based health care services and related supportive services (such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home). 15. Nursing care services (such as nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services) in a home, school, or other setting. 16. Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. 17. Dental services. 18. Inpatient substance abuse treatment services and residential substance abuse treatment services. 19. Outpatient substance abuse treatment services. 20. Case management services. 21. Care coordination services. 22. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders.

Effective Date: October 1, 2020

Approval Date: 23. Hospice care. 24. Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services (whether in a facility, home, school, or other setting) if recognized by State law and only if the service is-- a. prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as defined by State law, b. performed under the general supervision or at the direction of a physician, or c. furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license. 25. Premiums for private health care insurance coverage. 26. Medical transportation. 27. Enabling services (such as transportation, translation, and outreach services) only if designed to increase the accessibility of primary and preventive health care services for eligible low- income individuals. 28. Any other health care services or items specified by the Secretary and not excluded under this section.

TARGETED LOW-INCOME CHILD DEFINED- For purposes of this title-- 1. IN GENERAL- Subject to paragraph (2), the term ‘targeted low-income child’ means a child-- a. who has been determined eligible by the State for child health assistance under the State plan; b. (i) who is a low-income child, or (ii) is a child whose family income (as determined under the State child health plan) exceeds the Medicaid applicable income level (as defined in paragraph (4)), but does not exceed 50 percentage points above the Medicaid applicable income level; and c. who is not found to be eligible for medical assistance under title XIX or covered under a group health plan or under health insurance coverage (as such terms are defined in Section 2791 of the Public Health Service Act). 2. CHILDREN EXCLUDED- Such term does not include-- a. a child who is a resident of a public institution or a patient in an institution for mental diseases; or b. a child who is a member of a family that is eligible for health benefits coverage under a State health benefits plan on the basis of a family member's employment with a public agency in the State. 3. SPECIAL RULE- A child shall not be considered to be described in paragraph (1)(C) notwithstanding that the child is covered under a health insurance coverage program that has been in operation since before July 1, 1997, and that is offered by a State which receives no Federal funds for the program's operation. 4. MEDICAID APPLICABLE INCOME LEVEL- The term ‘Medicaid applicable income level’ means, with respect to a child, the effective income level (expressed as a percent of the poverty line) that has been specified under the State plan under title XIX (including under a waiver authorized by the Secretary or under Section 1902(r)(2)), as of June 1, 1997, for the child to be eligible for medical assistance under Section 1902(l)(2) for the age of such child. 5. TARGETED LOW-INCOME PREGNANT WOMAN.—The term ‘targeted low-income

Effective Date: October 1, 2020

Approval Date: pregnant woman’ means an individual— (A) during pregnancy and through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends; (B) whose family income exceeds 185 percent (or, if higher, the percent applied under subsection (b)(1)(A)) of the poverty line applicable to a family of the size involved, but does not exceed the income eligibility level established under the State child health plan under this title for a targeted low-income child; and (C) who satisfies the requirements of paragraphs (1)(A), (1)(C), (2), and (3) of Section 2110(b) in the same manner as a child applying for child health assistance would have to satisfy such requirements.

ADDITIONAL DEFINITIONS- For purposes of this title: 1. CHILD- The term ‘child’ means an individual under 19 years of age. 2. CREDITABLE HEALTH COVERAGE- The term ‘creditable health coverage’ has the meaning given the term ‘creditable coverage’ under Section 2701(c) of the Public Health Service Act (42 U.S.C. 300gg(c)) and includes coverage that meets the requirements of section 2103 provided to a targeted low-income child under this title or under a waiver approved under section 2105(c)(2)(B) (relating to a direct service waiver). 3. GROUP HEALTH PLAN; HEALTH INSURANCE COVERAGE; ETC- The terms ‘group health plan’, ‘group health insurance coverage’, and ‘health insurance coverage’ have the meanings given such terms in Section 2191 of the Public Health Service Act. 4. LOW-INCOME CHILD - The term ‘low-income child’ means a child whose family income is at or below 200 percent of the poverty line for a family of the size involved. 5. POVERTY LINE DEFINED- The term ‘poverty line’ has the meaning given such term in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section. 6. PREEXISTING CONDITION EXCLUSION- The term ‘preexisting condition exclusion’ has the meaning given such term in section 2701(b)(1)(A) of the Public Health Service Act (42 U.S.C. 300gg(b)(1)(A)). 7. STATE CHILD HEALTH PLAN; PLAN- Unless the context otherwise requires, the terms ‘State child health plan’ and ‘plan’ mean a State child health plan approved under Section 2106. 8. UNINSURED CHILD- The term ‘uninsured child’ means a child that does not have creditable health coverage.

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Wyoming WY-21-0018

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Programs Group May 25, 2021 Heather Gifford Kid Care CHIP Manager Wyoming Department of Health Division of Healthcare Financing 122 West 25th Sti·eet, 4 West Cheyenne, WY 82002 Dear Ms. Gifford: CMS CENTIRS FOR MEOICARE t, MEOICAIO SERVICES CENTER FOR MEDICAID & CHIP SERVICES Your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA), WY- 21-0017, submitted on Janua1y 5, 2021 and WY-21-0018, submitted on March 15, 2021, with additional infonnation submitted on May 25, 2021, has been approved. These SPAs allow the state to ti·ansition its separate CHIP program, Kid Care CHIP, to a Medicaid expansion program effective as of October 1, 2020. Through SPA WY-21-0017, the state removes references to its separate CHIP program throughout the state plan. This population transitioned to Wyoming's Medicaid state plan through Medicaid SPA WY-20-0008. SPA WY-21-0018 updates the income standards for the state's Medicaid expansion CHIP. Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Jordan's conta.ct infonnation is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-3413 E-mail: Joyce.Jordan@cms.hhs.gov If you have additional questions, please contact Meg Bany, Director, Division of State Coverage Programs at (410) 786-1536. We look fo1ward to continuing to work with you and your staff. Sincerely, /Signed by Amy Lutzky/ AmyLutzky Deputy Director

Page 1 of 1 CHIP Eligibility Transmittal Number: WY State Name: Wyoming OMB Control Number: 0938-1148 - 21 - 0018 Eligibility for Medicaid Expansion Program CS3 42 CFR 457.320(a)(2) and (3) Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered. Age and Household Income Ranges Add From Age To Age Above (% FPL) Up to & including (% FPL) Remove Add 0 6 154 200 Remove Add 6 19 119 200 Remove PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20181119 SPA# WY-21-0018 Approval Date: May 25, 2021 Effective Date: October 1, 2020

September 8, 2009

Mrs. Patricia Guzman Kid Care CHIP Manager & CHIP Director Wyoming Department of Health 6101 Yellowstone Rd, Suite 210 Cheyenne, WY 82002

Dear Mrs. Guzman:

We are pleased to inform you that your Children’s Health Insurance Program (CHIP) State plan amendment (SPA), submitted on May 18, 2009, has been approved. The effective date of this amendment is October 1, 2009. This amendment allows Wyoming to make changes to its cost sharing and enrollment procedures, including providing applicants with access to an online application and changing its process for implementing an enrollment cap under its existing State plan authority.

As you are aware, §42 CFR 457.720 of CHIP regulations require that State’s provide an assurance that “the State collects data, maintains records, and furnishes reports to the Secretary, at the times and in the standardized format, the Secretary may require to enable the Secretary to monitor State program administration and compliance and to evaluate and compare the effectiveness of State plans under title XXI.” Given the potential impact of Wyoming’s cost sharing increases on enrollees access to care, the Centers for Medicare & Medicaid Services (CMS) requests that the State regularly monitor the effect of these approved changes in cost sharing, collect and track the following data, and provide analysis of this data to CMS on a quarterly basis: 1) the number of children by Federal poverty level (FPL) that exceed the 5 percent maximum, 2) the number of families by FPL that exceed the 5 percent maximum, 3) the number of families by FPL that send in receipts when they do exceed the 5 percent cap, 4) impact on utilization of services, specifically services (e.g., dental, inpatient hospital, emergency room visits) with copayments that have significantly increased under this SPA, and 5) the percentage of children and families that reach the 5 percent maximum in a month, quarter, or year. We also request that the State survey enrollees on their experiences subsequent to the implementation of the cost sharing changes.

In addition, we want to ensure that Wyoming is aware of section 504 of the Children s Health Insurance Program Reauthorization Act (CHIPRA), which provides enrollees with a minimum

Page 2 – Mrs. Patricia Guzman

premium grace period before termination of coverage and became effective for coverage periods beginning on or after the February 4, 2009, date of enactment.

Your title XXI Project Officer is Ms. June Milby. She is available to answer questions concerning this amendment and other State CHIP related issues. Ms. Milby’s contact information is as follows;

Centers for Medicare & Medicaid Services

Center for Medicaid and State Operations

Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-8686

Facsimile: (410) 786-5882 E-mail: June.Milby@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Milby and to Mr. Richard Allen, Associate Regional Administrator for the Centers for Medicare & Medicaid Services, Region VIII, Division of Medicaid and State Operations. Mr. Allen’s address is: Mr. Richard Allen, ARA Centers for Medicare & Medicaid Services-Region VIII Colorado State Bank Building 1600 Broadway, Suite 700 Denver, Colorado 80202-4367

If you have additional questions, please contact Ms. Dianne Heffron, Acting Director, Family and Children’s Health Programs Group, Center for Medicaid and State Operations, at (410) 786-5647. We look forward to continuing to work with you and your staff.

Sincerely,

/s/

Charlene Frizzera Acting Administrator

Page 3 – Mrs. Patricia Guzman

cc: Mr. Richard Allen, Associate Regional Administrator, CMS Region VIII Office

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

Center for Medicaid, CHIP and Survey & Certification

August 12, 2010

Patricia Guzman Kid Care CHIP Manager & CHIP Director Wyoming Department of Health 6101 Yellowstone Rd, Suite 210 Cheyenne WY 82002

Dear Ms. Guzman:

This is to inform you that Wyoming’s seventh Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) submitted on June 3, 2010, has been approved. This SPA makes necessary changes to implement mental health parity and to provide medically necessary oral health services, including orthodontia. In addition, the amendment implements the Children’s Health Insurance Program Reauthorization Act requirements for prospective payments for Federally Qualified Health Centers and Rural Health Centers.

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

Centers for Medicare & Medicaid Services

Center for Medicaid, CHIP and Survey & Certification

Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-8686

Facsimile: (410) 786-5882 E-mail: June.Milby@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Milby and to Richard Allen, Associate Regional Administrator for the Centers for Medicare & Medicaid Services, Region VIII, Division of Medicaid and State Operations. Mr. Allen’s address is:

Centers for Medicare & Medicaid Services Division of Medicaid and Survey & Certification Colorado State Bank Building 1600 Broadway Suite 700 Denver, CO 80202

Page 2 - Patricia Guzman

If you have additional questions, please contact Ms. Victoria Wachino, Director, Family and Children’s Health Programs Group, Center for Medicaid and Survey & Certification, at (410) 786-5647. We look forward to continuing to work with you and your staff.

Sincerely,

/s/

Cindy Mann Director

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

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

State/Territory: __________________Wyoming__________________________________________ (Name of State/Territory)

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

_________________________________________/s/___________________________________ ___ Brent D. Sherard, M.D., M.P.H., Director and State Health Officer Wyoming Department of Health

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

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Patricia Guzman Position/Title: CHIP Director Name: Kellie Grady Position/Title: Deputy CHIP Director Name: Position/Title:

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

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

Original State Plan:

Effective Date:

4/1/99

Implementation Date: 12/1/99

Amendment #1:

Effective Date:

June 13, 2001

Implementation Date: Not implemented

Amendment #2:

Effective Date:

July 1, 2002

Implementation Date: July 1, 2002

Amendment #3:

Effective Date:

July 1, 2003

Implementation Date: July 1, 2003

Amendment #4:

Effective Date:

July 1, 2005

Implementation Date: July 1, 2005

Amendment #5:

Effective Date:

July 1, 2007

Implementation Date: July 1, 2007

Amendment #6:

Effective Date:

October 1, 2009

Implementation Date: October 1, 2009

Amendment #7 Mental Health Parity, Medically Necessary Orthodontia & Medically Necessary & Dental Services

Effective Date: July 1, 2010

Implementation Date: July 1, 2010

Prospective Payment System to FQHC’s and RHC’s Effective date: October 1, 2009 Implementation date: September 1, 2010

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

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

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

The Department of Health, Children’s Health Insurance Program Office has primary responsibility for the operation of Kid Care CHIP. Wyoming has very little to no managed care in the state. Because of this Wyoming will rely primarily on one insurance plan for coverage under Kid Care CHIP.

An RFP is issued to private health insurance carriers every two to three years. Carriers are asked to propose plans that provide the required basic level of benefits that was set by Wyoming state statute and the Health Benefits Committee. A contract is awarded to one insurance company that in its proposal best addresses: price, level of benefits, provider network, outreach efforts, cost sharing, marketing, member rights, access to care, grievance procedures and continuation of a private pay basis if the family ceases to be eligible for CHIP.

Financing for Kid Care CHIP will be through Federal CHIP allotments matched by State General Funds.

Kid Care CHIP will follow the process described in the State Health Official letter (Page 3 – Supplemental Payments to FQHC and RHC Managed Care Subcontractors) to pay the supplemental payments to these organizations. Kid Care CHIP will be implementing an APM as part of this PPS requirement utilizing the Medicaid PPS rates that are already established in the state.

The supplemental payment amount will be calculated as follows:

• Our Contractor will pay their regular negotiated rate for each claim (so if they normally pay $85 for an office visit then they will pay $85). The Health plan will reimburse less than the APM and the supplement will pay up to PPS

• Then, each quarter, the contractor will run a report for Kid Care CHIP that shows every claim for each FQHC and RHC in the state and what they paid.

• Kid Care CHIP will then take the Medicaid PPS rate that is already established and compare that to the rate that contractor paid.

• Kid Care CHIP will then calculate what is owed based on the difference between what is paid by the contractor and what the PPS rate is. (If the contractor paid $85 to an FQHC and the PPS rate is $210.00, then Kid Care CHIP will pay $125.55 difference)

• Kid Care CHIP will then pay the FQHC or RHC a lump sum payment every four months to make up this difference of all claims paid by the contractor in the last quarter.

The FQHC’s and RHC’s have been sent information and agreements to sign. They are due back by August 16, 2010. We have been in contact with them and have not heard of any disagreements to date.

State funding will come from State General Funds. The General Funds appropriated for the PPS payment system are funds that are specifically allocated to the Department of Health, Kid Care CHIP program.

Kid Care CHIP will be implementing this process with payments effective in September 2010. This change is being made as the system to make the payments will not be ready on July 1, 2010 as originally expected.

6.2.10.

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

First Level of Benefits: Services furnished in a hospital, including a state- operated mental hospital; a residential or other 24-hour therapeutically planned structural service; or a partial hospitalization program are covered. Twenty-one days of inpatient mental health benefits are covered per benefit year. Partial hospitalization benefits may be exchanged for inpatient days at a rate of one inpatient day for two partial treatment days. A partial hospitalization program that is operated by a hospital shall comply with the standards for a partial hospitalization program that are published by the American Association for Partial Hospitalization.

The following specific limitations apply to coverage depending upon the child’s diagnosis and the treatment setting. A child who has applied for or been found eligible for Kid Care CHIP prior to becoming a patient in an IMD will be covered by Kid Care CHIP within the individual benefit limits specified in this section. However, a child who is a patient in an institution for mental disease who did not apply for Kid Care CHIP prior to admission is not eligible for Kid Care CHIP until he or she is discharged from the IMD.

No limits to inpatient mental health shall be imposed on children diagnosed with the following disorders as defined by the American Psychiatric Association: Schizophrenia, schizoaffective disorder, bipolar disorder, major depression, panic disorder, obsessive-compulsive disorder, autism.

Second Level of Benefits:

The second level of benefits provides for an additional nine (9) days of care, for a total of thirty (30) days per benefit year, with pre-approval and case management by the Insurance Company. The insurance Company will work closely with the provider to ensure treatment plans are in place and managed.

Mental Health or substance abuse disorders diagnosed will be covered. Mental Health or substance abuse benefits will be provided in parity with meidcal/surgical benefits to the extent provided in the following categories: inpatient, outpatient, in-network, out of network, emergency and prescription drugs.

6.2.11.

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

First Level of Benefits: Professional outpatient mental health services up to a maximum of twenty visits per year are covered. The visits can be furnished in a variety of community based settings or in a mental hospital. Partial hospitalization benefits are paid as described in the inpatient mental health benefits section.

No limits to outpatient mental health benefits shall be imposed on children diagnosed with the following disorders as defined by the American Psychiatric Assoc: Schizophrenia, schizoaffective disorder, bipolar disorder, major depression, panic disorder, obsessive-compulsive disorder, autism.

Second Level of Benefits:

The second level of benefits provides for an additional twenty (20) outpatient visits per benefit year, for a total of forty (40) days per benefit year, with pre- approval and case management by the insurance Company. The insurance company will work closely with the provider to ensure treatment plans are in place and managed. Providers will have the capability to bill for partial (30 minutes or less) and full (more than 30 minutes) sessions. This capability only applies to the second level of benefits.

Mental Health or substance abuse disorders diagnosed will be covered. Mental Health or substance abuse benefits will be provided in parity with meidcal/surgical benefits to the extent provided in the following categories: inpatient, outpatient, in-network, out of network, emergency and prescription drugs.

6.2.17. Dental services (Section 2110(a)(17))

Kid Care CHIP will provide a State Defined Dental Benefit Package. This package will include requirements from section 2103(c)(5) of CHIPRA, including “coverage of dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.” Benefits include: Exams, cleanings, bitewing x-rays, fluoride treatments, sealants, full mouth x-rays, space maintainers, fillings, simple extractions, gold or porcelain crowns for teenagers with adult or permanent dentition, full mouth debridement for teenagers with permanent dentition, partials for teenagers with permanent dentition and missing anterior teeth, sedation for younger children, emergency treatment for the relief of pain, medically necessary dental services and medically necessary orthodontics. Annual maximum is $1,000 per benefit year. Preventive and diagnostic services (Exams, cleanings, fluoride, space maintainers, sealants and x-rays) are subject only to frequency limitations and are not included in the child’s yearly benefit maximum. Medically necessary dental services will be covered even if a child has reached their $1,000 annual maximum benefit.

6.2.18.

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

The combined benefit for inpatient and outpatient treatment for alcoholism and drug addiction, excluding costs for medical detoxification, is subject to a maximum benefit of $6,000 in a 12-month period, until a lifetime inpatient maximum benefit of $12,000 is met, after which the annual benefit may be reduced to $2,000. Costs for medical detoxification treatment must be paid the same as any other illness under the terms of the contract and are not subject to the lifetime limits.

Mental Health or substance abuse disorders diagnosed will be covered. Mental Health or substance abuse benefits will be provided in parity with meidcal/surgical benefits to the extent provided in the following categories: inpatient, outpatient, in-network, out of network, emergency and prescription drugs.

6.2.19.

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

The combined benefit for inpatient and outpatient treatment for alcoholism and drug addiction, excluding costs for medical detoxification, is subject to a maximum benefit of $6,000 in a 12 month period until a lifetime maximum inpatient benefit of $12,000 is met, after which the annual benefit may be reduced to $2,000. Costs for medical detoxification treatment must be paid the same as any other illness under the terms of the contract and are not subject to the lifetime limits.

Mental Health or substance abuse disorders diagnosed will be covered. Mental Health or substance abuse benefits will be provided in parity with meidcal/surgical benefits to the extent provided in the following categories: inpatient, outpatient, in-network, out of network, emergency and prescription drugs.

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

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c))

There are three levels of cost sharing: Plan A for enrollees up to 100% of the federal poverty level & Native American Children; Plan B for enrollees 101% through 150% of the federal poverty level; and Plan C for enrollees 151% through 200% of the federal poverty level.

8.2.1. Premiums: No premiums will be charged to families. 8.2.2. Deductibles: No deductibles will be charged to families Coinsurance or copayments: Plan A: No Co-payments for Services

Plan B:

Benefits Co-payments Total Family Out of Pocket Maximum per Benefit Year

5% of the family’s gross yearly income** Medical and Vision Out of pocket maximum per benefit year

$200 per child

Office visits (including mental health) $5

Well Child Exams No-copayment required

Immunizations No co-payment required

Lab and X-ray No-co-payment required

Outpatient Hospital $5

Inpatient Hospital $30

Emergency Room $5 Pharmacy out of pocket maximum per benefit year

$100 per child

Generic prescriptions $3

Brand name prescriptions $5

Dental out of pocket maximum per benefit year

$15 per child $15 per child - orthodontics

Preventive and Diagnostic Services (exams, cleanings, No co-payment required

flouride, sealants)

Basic and Major Services (fillings, extractions, etc) $5 per visit

Medically Necessary Orthodontics $5 per visit **Kid Care CHIP will send families an approval letter telling them the out of pocket maximum amount for their family.

Plan C:

Benefits Co-payments Total Family Out of Pocket Maximum per Benefit Year

5% of the family’s gross yearly income** Medical and Vision Out of pocket maximum per benefit year

$300 per child

Office visits (including mental health) $10 per child

Well Child Exams No Co-payment Required

Immunizations No Co-payment Required

Lab and X-ray No Co-payment Required

Outpatient Hospital $10

Inpatient Hospital $50

Emergency Room $25 Pharmacy out of pocket maximum per benefit year

$200 per child

Generic prescriptions $5

Brand Name prescriptions $10

Dental out of pocket maximum per benefit year

$75 per child $75 per child - orthodontics

Preventive and Diagnostic Services (exams, cleanings, flouride, sealants) No co-payment required

Basic and Major Services (fillings, extractions, etc) $25 per visit

Medically Necessary Orthodontics $25 per visit

Kid Care CHIP mailed cost sharing updates to families on April 30, 2010 that outlined upcoming changes to the program. This document was also provided to provider offices and any other organization partnering with Kid Care CHIP to conduct outreach and enrollment activities. Revisions to our benefit books from both Blue Cross Blue Shield and Delta Dental of Wyoming were also mailed to families in June 2010. These revisions outline the upcoming changes to the benefits and cost sharing in Kid Care CHIP.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures Deleted: ¶

required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c))

As indicated in section 4.4.5 Kid Care CHIP works directly with the tribes, the Tribal Health Services and the Indian Health Service to inform Native Americans in Wyoming about Kid Care CHIP. The representatives of the tribes and organizations in the state have been in all state-wide partnerships and individual relationships have been made, which assures their input in the design of an effective outreach and marketing campaign for Kid Care CHIP that will be acceptable to the tribes.

Kid Care CHIP presented upcoming changes to Indian Health Services, Wind River Health Systems and other organizations on the reservation in May 2010.

Kid Care CHIP attempted to present to the Joint Tribal Councils, twice (once in May and once in June) but due to Tribal Council cancellations & recent flooding we were unable to present to them in person. We have contacted their offices but have not received any comments back from the Tribal Council on the documents we provided to them.

The meeting with Wind River Health Systems was attended by Indian Health Services, Tribal Council Members, Wind River Health Systems, Public Health, School officials, WIC and Head Start officials.

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

Public Notice for all cost sharing changes to Kid Care CHIP will be made according to State law. The public notice for the public meeting and rules will be published in Wyoming newspapers and the public meeting will be held within no less than thirty days prior to implementation. The published notice will advise of the changes being made to Kid Care CHIP cost sharing. As an additional step, the Department of Health will also address the cost sharing in the public notice for the administrative rule for Kid Care CHIP that will be issued prior to October 1, 2009. July 2010.

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

 Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and

- Assumptions on which the budget is based, including cost per child and expected enrollment.  Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

SCHIP Budget Plan Template Wyoming

Federal Fiscal Year 2010 2011 Costs Enhanced FMAP rate 65.00% Benefit Costs

Insurance payments

Managed care

per member/per month rate @ # of eligibles

FQHC & RHC Managed Care PPS payments Med. Necessary Ortho @ # of estimated eligibles $214.13 @ 5980 $223.50 @ 5505 $150,000 $168,750 Fee for Service

Total Benefit Costs $15,040,491 $14,764,410 $150,000 $168,750

(Offsetting beneficiary cost sharing payments) $0 Net Benefit Costs*** $15,040,491 $15,083,160

Administration Costs

Personnel $552,850 $526,532 General administration $ 72,669 Contractors/Brokers (e.g., enrollment contractors) $136,950 $96,000 Claims Processing Included in Premiums Outreach/marketing costs $53,417 $34,000 Other (Indirect/Rent) $132,818

Total Administration Costs $948,704 $862,019 10% Administrative Cost Ceiling $1,508,332

$1,508,316

Federal Share (multiplied by enh-FMAP rate) $10,392,977 $10,364,366 State Share $ 5,596,218 $5,580,813 TOTAL PROGRAM COSTS $15,989,195 $15,945,179 Note: The Federal Fiscal Year (FFY) runs from October 1st through September 30th.

Funding: State funding will come from one source: State General Funds.

***Net Benefit Costs are based on enrollment by month multiplied by the premium of $214.13 $223.50.

Below please find estimated enrollment for Kid Care CHIP by month * does not include FQHC/RHC PPS or Medically Necessary Orthodontia (10/10-9/11)

Month Enrollment Number Total Premium Federal State 10/10 5450 $1,218,075 $791,749 $426,326.25 11/10 5460 $1,220,310 $793,202 $427,108.50 12/10 5470 $1,222,545 $794,654 $427,890.75 1/11 5480 $1,224,780 $796,107 $428,673.00 2/11 5490 $1,227,015 $797,560 $429,455.25 3/11 5500 $1,229,250 $799,013 $430,237.50 4/11 5510 $1,231,485 $800,465 $431,019.75 5/11 5520 $1,233,720 $801,918 $431,802.00 6/12 5530 $1,235,955 $803,371 $432,584.25 7/12 5540 $1,238,190 $804,824 $433,366.50 8/12 5560 $1,242,660 $807,729 $434,931.00

PPS for FQHC’s and RHC’s: In the first two quarters of FFY 2010, the difference between the payments made by Blue Cross Blue Shield and Delta Dental of Wyoming and the PPS rates established by Wyoming Medicaid equaled approximately $75,000. Since this is the data we have to date we are utilizing this to make our estimates for the next year. $75,000 x 2 = $150,000 for one year. $150,000 x 2 = $300,000 for two years.

Medically Necessary Orthodontia: $3,750 maximum per child x 45 children (estimated) = $168,750 Deleted: TOTAL ...

Personnel Kid Care CHIP will have seven positions dedicated to administering the program.

Supportive Services General operations costs include equipment, travel, office supplies, and postage, printing, and telephone toll charges.

Case Services Estimated monthly premium is $214.13 $223.50 based on the programs most recent contract that was issued in 2009 2010. Contractual Services The services listed below will be contracted services:

Consultant services to conduct research and assist in the design and implementation of the eligibility system for Kid Care CHIP.

Legal fees for the development of administrative rules

Sources of Non-Federal Share of Expenditures In addition to federal funds, Kid Care CHIP State general fund appropriations will be used. Enrollment projections are based on current estimates of funds which will be appropriated for Kid Care CHIP. If enrollment expectations exceed those projected for funding, new enrollment may be suspended.

Approval Package

Approval Package

Current State Plan

Approval Package

Approval Package

Approval Package

Approval Package

Approval Package

Factsheet

Current State Plan

Approval Package

Final Approved State Plan

Approval Package