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Table of Contents

State/Territory Name: Alabama

State Plan Amendments (SPA) #: AL-19-0017-RIM and AL-19-0018-RIM

This file contains the following documents in the order listed:

1) Approval Letter 2) Approved SPA Template 3) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-01-1ó Baltirnore, MD 21244-"1850 ctNl¡R:l foß MfDrc Rt & Mf,Dtc tD sERvtcfs CENÍFßcursTON MEDICAID & CHIP SFßVICES Children and Adults Health Prosrams Grouo

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Ms. Teela Sanders Acting Director, Children's Health Insurance Program 201 Monroe Street Montgomery, AL36104

Dear Ms. Sanders

Your title XXI Children's Health Insurance Program (CHIP) state plan amendments (SPA) AL- 19-0017-RIM and AL-19-0018-RIM have been approved. These SPAs have an effective date of July 1 ,2019.

SPA number AL-19-0017-RIM permits Alabama to implement a health services initiative (HSI) to provide prenatal monitoring, case management and care coordination services to low-income, high-risk pregnant women and their infants in Montgomery, Macon, and Russell counties in order to improve pregnancy outcomes and infant health. Patients will receive services during pregnancy and for up to one year post delivery.

Section 2105(aXlXDXii) of the Social Security Act (the Act) and 42 CFR 9457.10 authorize use of title XXI administrative funding for expenditures for HSIs under the plan for improving the health of children, including targeted low-income children and other low-income children. Consistent with section 2105(c)(6)(B) of the Act and 42 CFR 9457.626, title XXI funds used to support an HSI cannot supplant Medicaid or other sources of federal funding.

The state shall ensure that the remaining title XXI funding, within the state's l0 percent administrative limit, is sufficient to continue the proper administration of the CHIP program. If such funds become less than sufficient, the state agrees to redirect title XXI funds from the support of this HSI to the administration of the CHIP program. The state shall report annually to CMS the expenditures funded by the HSI for each federal fiscal year.

SPA number AL-19-0018-RIM permits Alabama to expand coverage for unborn children residing in Montgomery, Macon, and Russell counties with family incomes up to, and including 312 percent of the federal poverty level (FPL) whose pregnant mothers are not otherwise eligible for Medicaid. Coverage will include pregnancy-related services including prenatal care for children from conception to birth. A copy of the approved CS9 is attached and is incorporated in section 4.1.9 of the current Alabama CHIP state plan.

Your title XXI project officer is Ms. Cassie Lagorio. She is available to answer questions concerning this amendment and other CHlP-related issues. Ms. Lagorio's contact information is as follows:

Page2 - Ms. Teela Sanders Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services, Mail Stop S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1 850 Telephone: (410) 786-4554 E-mail: Cassandra.Lagoño@cms.hhs.gov

Offrcial communications regarding program matters should be sent simultaneously to Ms. Lagorio and to Ms. Shantrina Roberts, Deputy Director, Division of Medicaid Field Operations South. Ms. Robertsos address is:

Centers for Medicare & Medicaid Services Division of Medicaid Field Operations South 6l Forsyth Street, SV/, Suite 4T20 Atlanta, GA 30303-8909

V/e look forward to continuing to work with you and your staff.

Sincerely,

/signed Anne Marie Costello/

Director

cc: Ms. Shantina Roberts, Deputy Director, Division of Medicaid Field Operations South

CHIP Eligibility

State Name: Alabama OMB Control Number: 0938‐1148

Transmittal Number: AL - 19 - 0001 Separate Child Health Insurance Program CS9 Eligibility - Coverage From Conception to Birth

42 CFR 457.10

■ Coverage From Conception to Birth - Coverage from conception to birth when the mother is not eligible for Medicaid.

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

Age Standard

From conception through birth.

Does the state have an additional age definition or other age-related conditions? No

Income Standards

Income standards are applied statewide. No

Select a method of geographic variation:

Standard varies by county or city.

Standard varies in some other geographic way.

In each row of the table, you may enter one county if the county has an income standard that is unique to that county. If multiple counties share the same income standard, enter all the counties first, then enter the income standard that applies to those counties.

Add Counties From zero up to (% FPL) Remove

Montgomery, Macon, and Russell Counties 312 Add Remove

Do you have any cities within your state which have their own separate income standards? No

■ Exempted from requirement of providing or applying for a Social Security Number.

■ Exempted from requirement of verifying citizenship status.

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 number: AL-19-0018-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019 Page 1 of 1

TEMPLATE FOR CHILD HEALTH PACWLAN 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: Alabama (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)) Scott Harris, State Health Officer, Alabama Department of Public Health (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: Teela Sanders Position/Title: CHIP Director Name: Jeffrey Wright Position/Title: Director, ADPH Financial Services 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.

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 1 Approval Date:

Introduction:Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 105-33amended 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). Itreflects the regulatoryrequirements at 42 CFR Part 457as 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 Requirementsfor 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. ASPA 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 SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 2 Approval Date:

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 StateApproach 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)); (42CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 3 Approval Date:

health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary- approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The 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 SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

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

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)

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 5 Approval Date:

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

ProposedState 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

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 6 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

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))

* Until October 1, 2002, Alabama’s CHIP was a combination program. With the mandated gradual increase of Medicaid coverage at higher income levels for children born after September 30, 1983, the Medicaid expansion portion of CHIP was subsumed, on October 1, 2002, by the Alabama Medicaid SOBRA Program for Pregnant Women and Children.

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))

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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Alabama has not and will not claim expenditures for child health assistance prior to the time that the State has legislative authority to operate the State 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. (42CFR 457.130)

Assurances are on file with DHHS. The Alabama Department of Public Health continues to assure that compliance with all applicable civil rights requirements.L

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:February 1, 1998 Amendment 1 – Establishment of ALL Kids Effective Date: February 1, 1998 Implementation Date: October 1, 1998 Amendment 2 – Establishment of ALL Kids PLUS Effective/Implementation Date: October 1, 1999 Amendment 3 – Disregards Effective/Implementation Date: June 1, 2001 Amendment 4 - Compliance Effective/Implementation Date: August 24, 2001 Amendment 5 – Waiting List, Cost Sharing, Benefit Changes Effective/Implementation Date: October 1, 2003 Amendment 6 – Discontinuance of the Waiting List and other Clean-Up changes SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 8 Approval Date:

Effective/Implementation Date: November 23, 2004 Amendment 7 – Raise the upper income eligibility limit to 300% of FPL and other minor changes Effective/Implementation Date: October 1, 2009 Amendment 8 – Include a private foundation grant as an additional source of state funding Effective/Implementation Date: October 27, 2009 Amendment 9 – Establishment of a Prospective Payment System for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) Effective/Implementation Date: October 1, 2009; Addendum on Dental Benefits Under Title XXI: Effective/Implementation Date: October 1, 1998 Amendment 10 – Eligibility for children of employees of a public agency (state employees and public education employees) Effective/Implementation Date: January 1, 2011 Amendment 11 – Provisions for Implementing Temporary Adjustments to Enrollment Determination and/or Redetermination Policies and Cost Sharing Requirements for Applicants/Renewals living in and/or working in FEMA or Governor declared disaster areas at the time of a disaster event. In the event of a disaster, the State will notify CMS of the intent to provide temporary adjustments to its enrollment and/or redetermination policies, the effective dates of such adjustments and the counties/areas impacted by the disaster. Effective/Implementation Date: April 15, 2011 Amendment 12 – Increase premiums, increase co-pays and revise the methodology for determining annual aggregate cost-sharing Effective/Implementation Date: May 1, 2012 Amendment 13 – Establishment of copayments for therapy services (physical, occupational, and speech), vision services and chiropractic services; and cleanup changes Effective/Implementation Date: August 1, 2013 Amendment 14 – Alignment of ALL Kids fee groups with provisions of the Affordable Care Act (ACA) and other editorial changes to comply with previously approved ACA SPAs. Effective/Implementation Date: January 1, 2014 Amendment 15 - AL-16-0015-MEXP – CHIP Medicaid expansion to cover Medicaid enrollees ages 14 years to 19 years with incomes above 18% FPL through 141% FPL. Effective Date: October 1, 2015 Implementation Date: January 1, 2016 Amendment 16 – AL-18-0016-PAR - Attestation and documentation of Mental SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 9 Approval Date:

Health Parity and Addiction Equity. Submission Date: July 10, 2018 Proposed Effective Date: October 1, 2017* Implementation Date: October 1, 2017* *Note: Benefits were adjusted in October 2010 to be compliant with mental health parity; this amendment did not require any benefit changes Amendment 17 – AL-19-0017-RIM - Reducing Infant Mortality (RIM) Health Service Initiative Submission Date: July 17, 2019 Proposed Effective Date: July 1, 2019 Implementation Date: July 1, 2019 Amendment 18 – AL-19-0018-RIM CS9 Eligibility – Coverage From Conception to Birth Submission Date: July 17, 2019 Proposed Effective Date: July 1, 2019 Implementation Date: July 1, 2019

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 10 Approval Date:

Transmittal Number SPA PDF Description Superseded Group # Plan Section(s) AL-14-0016 MAGI CS7 Eligibility – Targeted Low Supersedes the Eligibility Income Children current & sections Effective/Implementati Methods Geographic on Date: January 1, Children With Access to Area 4.1.1; Age 2014 CS10 Public Employee Coverage 4.1.2; and Income 4.1.3 Section 4.4.1: Supersedes only the MAGI-Based Income information on CS15 Methodologies dependents of public employees in this section; supporting documentation should be incorporated as an appendix to the current state plan

Incorporate within a separate subsection under section 4.3

AL-19-0018-RIM CS9 Coverage from Conception Effective Date: July 1, to Birth 2019 Implementation Date: July 1, 2019

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 11 Approval Date:

Transmittal Number SPA PDF Description Superseded Group # Plan Section(s) (Original: AL-14-0014 XXI CS3 Eligibility for Medicaid Supersedes the Effective/Implementatio Medicaid Expansion Program current n Date: January 1, 2014) Expansio Medicaid n expansion AL-16-0015-MEXP CHIP Medicaid expansion section 4.0 to cover Medicaid Effective/Implementati enrollees ages 14 years to on Date: October 1, 19 years with incomes 2015 above 18% FPL through 141% FPL AL-14-0015 Establish CS14 Children Ineligible for Incorporate 2101(f) Medicaid as a Result of the within a Effective/Implementati Group Elimination of Income separate on Date: January 1, Disregards subsection 2014 under section 4.1 AL-14-0018 Eligibility CS24 Single, Streamlined Supersedes the Process Application current Effective/Implementati Screen and Enroll Process sections 4.3 on Date: January 1, Renewals and 4.4 2014 AL-14-0017 Non- CS17 Non-Financial Eligibility – Supersedes the Financial Residency current section Effective/Implementati Eligibility 4.1.5 on Date: January 1, CS18 Non-Financial – Citizenship 2014 Supersedes the CS19 Non-Financial – Social current Security Number sections 4.1.0; 4.1.1-LR; 4.1.1- CS20 Substitution of Coverage LR

CS21 Non-Payment of Premiums Supersedes the current section CS27 Continuous Eligibility 4.1.9.1

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 12 Approval Date:

Transmittal Number SPA PDF Description Superseded Group # Plan Section(s)

Supersedes the current section 4.4.4

Supersedes the current section 8.7

Supersedes the current section 4.1.8

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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1.4- TC Tribal Consultation(Section 2107(e)(1)(C))Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. TN No: Approval Date Effective Date: October 1, 2015 In accordance with approved policies, on January 10, 2019, a certified letter explaining the changes proposed in AL-19-0017-RIM and AL-19-0018-RIM was mailed to the Tribal Chairman of the one federally recognized Native American tribe in Alabama, the Poarch Band of Creek Indians. The letter included the purpose for the proposed changes and a description of the changes. In the letter, the Tribal Chairman was also reminded that she had the opportunity to respond to the proposed changes within 30 days and was given contact information for any such response. The certified letter was signed by the CHIP Director. TN No: Approval Date Effective Date: February 10, 2019

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

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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requirements). (Section 2102(a)(1)); (42 CFR 457.80(a)) Prior to CHIP, the only two programs offering health insurance to low-income children were Medicaid and the Alabama Child Caring Foundation (ACCF). Medicaid served children at the minimum income levels required by federal law. This meant that Medicaid coverage was available to children at three different levels of income and age: - Those under the age of six (6) years with incomes up to 133% FPL; - Those children six (6) through 14 years of age who were born after September 30, 1983 with incomes up to 100%FPL; and, - Those remaining children through the age of 18 years (middle and older teens) with incomes at the TANF assistance level (below approximately 13% FPL). The ACCF served children (birth through 18 years) with incomes from the Medicaid levels up to 200% FPL.

From February 2, 1998 through September 30, 2002, Phase I of CHIP, a Medicaid expansion was in existence. On October 1, 2002, Phase I of Alabama’s CHIP was subsumed by the Alabama SOBRA Medicaid Program. Beginning October 1, 2015, however, children in this category (ages 14 to 19 with incomes between 13% FPL and 141% FPL) will again be enrolled in a CHIP Medicaid expansion.

Originally, CHIP used a baseline number of uninsured children derived from the Current Population Survey (CPS). This baseline including the following chart was derived from a study by Winterbottom et.al. based on a three year merged Current Population Survey, or CPS, (1990-92), which showed over 200,000 children, in Alabama, under 18 years to be uninsured.

Employer Medicaid Other Uninsured Coverage Percent 59.3 17.2 5.1 18.4 Number 652,300 189,200 110,000 202,400

However, due to concerns about the CPS regarding potential problems with subjects’ abilities to recall information, Alabama changed its baseline estimate to reflect data from the 1997 round of the Urban Institute’s National Survey of America’s Families (NSAF). The NSAF indicated that there were 173,012 uninsured children in Alabama. Of these, 91,209 were < 100% Federal Poverty Level (FPL), 49,579 were above 100 up to 200% FPL and 32,223 were >200% FPL.

In its first 4 years of implementation (October 1, 1998 – September 30, 2002), Phase II, ALL Kids, enrolled over 80,000 children. It is estimated that 52,000 children have current enrollment in ALL Kids at the end of FY 2002.

ALL Kids PLUS, added as a third amendment to the CHIP State Plan (October, 1999), serves SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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as a mechanism by which children with special health care needs/conditions (CSHCN/C), who are enrolled in ALL Kids, may receive health and health related services which are beyond the scope of the basic ALL Kids package. ALL Kids PLUS was designed so that it serves as a funding source for CHIP state match and as a funding mechanism for state agencies who serve CSHCN/C with state funds. State agencies participating in ALL Kids PLUS supply the state match, provide the service, and receive full reimbursement. It was originally estimated that approximately 9% of these enrollees would also receive at least one service under ALL Kids PLUS. However because the basic benefit package is so comprehensive, a much lower percentage of children are receiving PLUS services. It is expected that this percentage will increase as more state agencies contract with CHIP to become ALL Kids PLUS providers. With the advent of ALL Kids, the ACCF has changed its income eligibility criteria to serve children who are not eligible for Medicaid or ALL Kids and who have incomes up to 235% FPL. Because, the ACCF has no enrollment restriction regarding immigrants, this program has seen a dramatic increase in its Hispanic enrollment.

Guidance: Section 2.2allows 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 at42 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) As permitted under section 2105(a)(1)(D)(ii) of the Social Security Act and federal regulations at 42 CFR 457.10, the State of Alabama is implementing a health services initiative (HSI) that will use CHIP funds, within the federal administrative expenditures cap allowed for states, to support the Reducing Infant Mortality (RIM) Health Services Initiative. The aim of this initiative is to reduce the infant mortality rate in selected counties within Alabama through the provision of a variety of evidence-based case management services for pregnant women and children. These case management services will target health, social, and behavioral health related high-risk factors which have been shown to impact pregnancy outcomes and infant health. Case Management services will connect patients, with high-risk factors, to appropriate services and case managers will follow-up to ensure that risk factors are being addressed satisfactorily. It is anticipated that the case manager will make a total of 6 face to face visits. Three visits would occur during the prenatal care, and three visits would be provided post delivery.

The care coordination services provided postpartum including services to the infant include:

i. Make home visit within one month following delivery to complete the following: 1. Encourage patient to keep postpartum appointment including providing appointment SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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reminders to help ensure completion of the postpartum appointment. 2. Encourage patient to choose a reliable birth control method. If the patient has chosen sterilization as her method, follow-up with the patient to ensure the procedure is completed. 3. Ensure patient is established with a PMP for the infant. 4. Ensure infant has enrolled in WIC, if eligible. 5. Educate the patient on the importance of immunizations for the infant. ii. Assist in scheduling appointments with infant’s PMP up to the first year to ensure that well baby checkups are made and immunizations are up to date. Follow up after the appointments to verify that appointments were kept. Well Baby checkups are scheduled at: a. 1 month b. 2 months c. 4 months d. 6 months e. 9 months f. 12 months iii. Promote the child’s overall physical, cognitive, and emotional development through educating parents/caregivers about developmental milestones according to the child’s age and developmental abilities. iv. Complete an ASQ-3 (Ages and Stages Questionnaire, Third Edition, a developmental screening tool) as appropriate at face to face appointments. v. Educate the parents about the importance of reading to the infant to promote cognitive development. vi. Make referrals for the child, as appropriate, such as Early Intervention, Children’s Rehabilitation Services, etc. vii. Prior to the child’s first birthday, ensure he/she is established with a dentist. viii. Screen the mother for post-partum depression at each face to face visit and make referrals and follow up (as needed)

With the exception of providing necessary prenatal monitoring by a nurse in the home or health department setting, no HSI funds will be spent on direct care.

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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The high-risk factors that HSI will address include the following: ACEs Score of >4 Depression1 Diabetes Mellitus Current multiple births Substance Abuse2 Maternal age3 Hypertension Interpersonal safety Transportation needs Housing Instability Food Insecurity Utility needs Abuse4 Enrollment in CHIP unborn coverage Prior poor pregnancy outcome5

To be eligible for the HSI, pregnant women and/or their infants in selected counties must have at least one of the high-risk factors cited above and have an income no greater than the upper CHIP limit (currently 312% FPL). HSI services will be offered whether or not the patient has health insurance coverage and regardless of the type of insurance. Case management services for individuals enrolled in Medicaid will be time-limited until the implementation of the case management services provided in the Alabama Coordinated Health Network (ACHN) scheduled to begin October 1, 2019. Individuals with other insurance that are provided case management services will not be provided case management services using HSI funds.

Patients will be enrolled in the HSI initiative during pregnancy, during the post-partum period, or by referral. Once enrolled, HSI services will continue, as appropriate, for one-year post delivery with the exceptions noted in the paragraph above.

The HSI will be coordinated by the Alabama Department of Public Health and delivered through designated county health departments. Depending upon the needs of those participating in the initiative, services may be provided by public health nurses, public health social workers, community health workers, etc.

The proposed counties for initial implementation of the HSI include Montgomery, Macon and Russell counties. Services supported through this HSI will not supplant other federal, state or local funds allocated for similar services.

Outreach activities for the RIM HSI include providing education and information to pertinent providers, hospitals and programs serving the target population residing in the counties in which the expansion is implemented.

1 Depression noted at anytime during the pregnancy or postpartum period (90 days postpartum) 2 History of use or current substance use 3 <21 or >35 4 Emotional, physical, or sexual 5 Fetal Death – Stillbirth after 20 weeks; Infant death -first year of life; Preterm birth - <37 weeks gestation; Low Birthweight - <2500 grams; Very Low Birthweight - <1500 grams; Other serious chronic conditions (ex: heart disease, renal disease, chronic medical illnesses, etc.); and, Maternal Death (death of a woman while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes). SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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In monitoring/evaluating the progress and success of this program, the total number of women and children served will be captured and reported to ALL Kids on an agreed upon schedule but no less than a quarterly basis. Tracking and reporting of visits and birth outcomes (birth weight, mortality within the first year of life and maternal health indices) will also be included in reports to ALL Kids.

The cost of the HSI is budgeted to be $753,625 for FY 2019 (July –Sept).

Case Management Costs: Initially, within the proposed three county area, approximately 500 women/families could be served in FY 2019. The number of case management hours per person/family is estimated to be 10 hours/quarter at an average cost of $135/hour. This hourly rate would account for salary cost of those providing/coordinating services. Additionally, it is estimated that staff will travel 25 miles per home visit and there will be two home visits/patient/quarter at the state mileage reimbursement rate of $0.545/mile.

Annual 1st Quarter Case Management: Enrollees X case management hours $2,700,000 $675,000 X $135.00/hour Travel: # enrollees X miles/round trip X 2 trips/quarter X mileage $ 54,500 $ 13,625 reimbursement rate

Start Up/Outreach Costs: As the HSI is being developed, costs are being allocated for personnel support to include up to two FTEs (one full-time project manager and other ancillary support staff as needed). Additionally, costs are included for the development of materials to promote and educate health care providers and community organizations throughout the implementation counties about the initiative and to garner support and participation of agencies/providers. Education and awareness materials to outreach to women will also be prepared. Expenses to conduct (as well as attend) meetings, conferences and/or trainings to share information about the program and generate participation are also included as part of the startup and implementation costs.

Annual 1st Quarter Personnel Costs (Salary, Fringe, Indirect costs) $200,000 $50,000 Educational/training materials $ 10,000 $10,000 (providers/organizations and participants) Costs for meetings (transportation/meeting fees) $ 5,000 $ 5,000

Grand Total: $2,969,500 $753,625 (Personnel, Materials, Meeting costs, Case Management)

2.3-TC Tribal Consultation Requirements-(Sections 1902(a)(73) and 2107(e)(1)(C)); SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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

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

ALL Kids provides a certified letter to the federally recognized tribe in the state when considering amendments to the State Plan or other program changes requiring CMS approval. The tribe is given 30 days to respond. In the event of an emergency, ALL Kids will submit a faxed letter to the tribe and give 10 days for response.

Section 3. Methods of Delivery and Utilization Controls Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4. Guidance: In Section 3.1., discussion may include, but is not limited to: contracts with managed health care plans (including fully and partially capitated plans); contracts with indemnity health insurance plans; and other arrangements for health care delivery. The State should describe any variations based upon geography, as well as the State methods for establishing and defining the delivery systems.

Should the State choose to cover unborn children under the Title XXI State plan, the State must describe how services are paid. For example, some states make a global payment for all unborn children while other states pay for services on fee-for-services basis. The State’s payment mechanism and delivery mechanism should be briefly described here.

Section 2103(f)(3) of the Act, as amended by section 403 of CHIPRA, requires separate or combination CHIP programs that operate a managed care delivery system to apply several provisions of section 1932 of the Act in the same manner as these SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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provisions apply under title XIX of the Act. Specific provisions include: section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. If the State CHIP program operates a managed care delivery system, provide an assurance that the State CHIP managed care contract(s) complies with the relevant sections of section 1932 of the Act. States must submit the managed care contract(s) to the CMS Regional Office servicing them for review and approval.

In addition, states may use up to 10 percent of actual or estimated Federal expenditures for targeted low-income children to fund other forms of child health assistance, including contracts with providers for a limited range of direct services; other health services initiatives to improve children’s health; outreach expenditures; and administrative costs (See 2105(c)(2)(A)). Describe which, if any, of these methods will be used.

Examples of the above may include, but are not limited to: direct contracting with school-based health services; direct contracting to provide enabling services; contracts with health centers receiving funds under section 330 of the Public Health Service Act; contracts with hospitals such as those that receive disproportionate share payment adjustments under section 1886(d)(5)(F) or 1923 of the Act; contracts with other hospitals; and contracts with public health clinics receiving Title V funding. If applicable, address how the new arrangements under Title XXI will work with existing service delivery methods, such as regional networks for chronic illness and disability; neonatal care units, or early-intervention programs for at-risk infants, in the delivery and utilization of services. (42CFR 457.490(a))

3.1. Delivery StandardsDescribe 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))

Phase I - Medicaid Expansion From February 2, 1998 through September 30, 2002, Phase I of CHIP, a Medicaid expansion was in existence. On October 1, 2002, Phase I of Alabama’s CHIP was subsumed by the Alabama SOBRA Medicaid Program. As of October 1, 2015, CHIP will again expand Medicaid by covering Medicaid enrollees ages 14 years to 19 years with incomes above 13% FPL through 141% FPL.

ALL Kids: SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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Program Operation–Administration From inception of the program in 1998 through May, 2001, ALL Kids contracted with the State Employee’s Insurance Board (SEIB) to serve as its enrollment and premium billing/receiving office. As enrollment grew, ALL Kids staff increased, and the need for data management grew, the ADPH CHIP unit and SEIB jointly decided to move the enrollment and premium billing/receiving functions to the CHIP unit. The Alabama Department of Public Health (Department) now manages all enrollment aspects of the ALL Kids program and utilizes other contractors to administer certain aspects of the ALL Kids program including, but not limited to, the following:

1. Providing all eligible persons involved in ALL Kids an individual policy or certificate that states the insurance protection provided, the method and place of filing claims, and to whom benefits are payable. The policy or certificate indicates that coverage was obtained through CHIP; 2. Maintenance of a claims database for the purpose of program management. 3. Management of evaluation surveillance procedures. 4. Consultation for actuarial services 5. Consultation for development of data systems 6. Consultation for development of specialized outreach plans

Program Operation-Benefits and Services The ALL Kids program is a self-funded, discounted fee-for-service*, PPO, delivery system. In order to assure delivery of the insurance product(s), the Department utilizes a private health care delivery organization(s) to provide benefits and services. Both indemnity plan(s) and or managed care plans(s) are acceptable and have been used. The selected vendor(s) is required to perform, including but not limited to, the following:

1. Furnishing coverage information and ID cards; 2. Member service responses to claims inquiries; 3. Claims certification, investigation, adjudication, and internal appeals process; 4. Processing and distribution of benefit payments to providers; 5. Appropriate and accurate fee administration; 6. Strict financial accounting and reconciliation; 7. Effective management of networks (if applicable); 8. Demonstrated capability to serve Alabama membership; 9. Effective medical, pharmacy and dental management including medical review of claims decisions; 10. Production of claims, contract, and other legal forms as required; 11. Establishment and maintenance of appropriate banking arrangements; 12. Continuous and accurate electronic transmission of all data; 13. Production of reports that capture claim and utilization experience and trends; 14. Other special services as may be requested from time to time 15. Have a network of physicians, dentists, pharmacies, and other providers capable of meeting SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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the demands of the ALL Kids Program. 16. Facilitation of a medical home for each enrollee.

*The exception to the fee-for-service payment system is the method of reimbursement to federally qualified health centers (FQHCs) and rural health clinics (RHCs) based on a prospective payment system (PPS). This is in compliance with section 503 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA). In accordance with this provision of CHIPRA, ALL Kids has elected to adopt the Medicaid PPS Rates effective October 1, 2009. This method of payment will be implemented August 25, 2010 for all qualifying services rendered on or after October 1, 2009.

In the past, ALL Kids has used three (3) insurance venders, Blue Cross Blue Shield of Alabama (statewide), Prime Health (in 10 southwestern counties from 10/98-9/00) and United Healthcare (14 counties from 10/01-7/02) for the above services. However, due to low enrollment in Prime Health and United Healthcare (which was due to patient choice), each of those programs elected, with the mutual consent of the ALL Kids program, to discontinue serving as an ALL Kids vendor. Currently, the only ALL Kids vendor for the above services is Blue Cross Blue Shield of Alabama. This vendor provides services statewide.

CHIP makes health care coverage available to all individuals eligible for ALL Kids on a “guaranteed issue” basis with no exclusions of coverage for pre-existing conditions, and on a “guaranteed renewable” basis for those eligible.

ALL Kids PLUS Program Operation-Administration For this addition to the program, the Alabama Department of Public Health has partnered (and seeks to partner) with other governmental agencies (which serve special needs children) to provide the state match, provide or provide for covered ALL Kids PLUS services, to authorize case by case reimbursement for ALL Kids PLUS services, to notify ALL Kids PLUS families of their approval for services, and select one case manager per child so as to minimize duplication and gaps in services. PLUS services became available through CRS as of October 1, 2000. An ALL Kids PLUS contract was signed with the Department of Mental Health and Mental Retardation effective October 1, 2002.

Several state agencies, other provider entities, and advocates within the state have met to develop the concept and plan of operation for ALL Kids PLUS.

At the present time, the list of ALL Kids PLUS authorizing agencies is restricted to those governmental agencies supplying the state match money. If other state or appropriated matching funds become available, this restriction may be modified or eliminated. A child must be enrolled in ALL Kids to qualify for PLUS services. When a child is identified with a special condition or need that a participating agency serves, he/she is referred to that agency based on that special condition/need. This agency will, based on the availability of funds, assign a case manager to the SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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child, authorize needed services within the agency, and make referrals to other authorizing agencies for additional services if needed. All agencies authorizing PLUS services for a child notify the child’s case manager and referral site (if different) for approval of services. Each child will only have one ALL Kids PLUS case manager. The decision as to which agency will provide the case management will be determined by the agencies involved in the child’s care and will be based on what makes the best practice sense and is in the best interest of the child.

Authorizing agencies bill the insurance vendor(s) for any authorized PLUS services that the agencies have provided directly or indirectly. The Alabama Department of Public Health reimburses the insurance vendor(s) in the same manner that reimbursement for the basic ALL Kids program is handled. At this time, the participating PLUS agencies do not utilize a central integrated data system. However, their day-to-day practice involves coordination through the case manager with other agencies to avoid duplication. Each agency submits all claims/data to the insurance vendor (BCBS) for adjudication and reimbursement. While a child may have claims submitted by more than one agency, only one agency may be reimbursed for case management services.

Check here if the State child health program delivers services using a managed care delivery model. The State provides an assurance that its managed care contract(s) complies with the relevant provisions of section 1932 of the Act, including section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. The State also assures that it will submit the contract(s) to the CMS Regional Office for review and approval. (Section 2103(f)(3))

Guidance: In Section 3.2., note that utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package.

Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after- hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42CFR 457.490(b))

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 SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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the approved State plan. (Section 2102)(a)(4) (42CFR 457.490(b))

Utilization control mechanisms are in place for the ALL Kids program to ensure that children use only health care that is appropriate, medically necessary, and/or approved by the State or the participating health plan. In addition, policies are in place to assure that necessary care is delivered in a cost-effective and efficient manner according to the vendors’ medical necessity definition. The current Blue Cross Blue Shield policies are available upon request.

Before being approved for participation in the ALL Kids program, health plan vendors must develop and have in place utilization review policies and procedures, demand management, and disease state management mechanisms. Provider networks approved for the ALL Kids program are accepted based on evidence of the vendors’ provider credentialing policies, provider accessibility, cost- effectiveness, and efficiency.

Each ALL Kids PLUS authorizing state agency has a utilization review mechanism particular to that agency. Services approved for ALL Kids PLUS are those which are developmentally necessary and/or physically necessary. Reviewing the appropriate use of services is part of the case manager’s duties.

The Alabama Medicaid Agency applies the same utilization controls to the CHIP Medicaid expansion enrollees as it does to the entire Medicaid child book of business. 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:

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

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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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 pregnantwomen (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 oftime in state):

4.1.6 Disability Status (so long as any standard relating to disability status does not restrict eligibility): Children will be eligible for ALL Kids regardless of disability. ALL Kids PLUS is available to children with special conditions/needs who are enrolled in ALL Kids. ALL Kids PLUS enrollment is restricted to services authorized and financed by PLUS participating agencies. However, if access to additional matching funds becomes available and/or the health needs of CSHCC/N change, authorized services will be revised to reflect these changes.

4.1.7 Access to or coverage under other health coverage:

A child is not eligible for ALL Kids if s/he has any other health insurance coverage or is eligible for Medicaid.

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,includingthose standards in 42 CFR 457.310 and 457.320 that are notaddressed above. For instance: Comprehensive health coverage will be provided from conception to birth for those with family incomes up to and including 312% FPL, whose mothers do not have SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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comprehensive coverage, and reside in select counties in Alabama (initially Montgomery, Macon and Russell). Full coverage will be provided to this population from the date of enrollment through delivery. The date of enrollment may be as early as the first day of maternity-related service provision even if the application is completed a few days after the service is received. In other cases coverage will begin on the date the application is received by the CHIP office. For example, if a woman gives birth on June 26, benefits covered in the bundled package would end on August 31. Only bundled services will be covered after delivery; coverage for other benefits will cease upon delivery. Coverage for bundled obstetrical benefits begins upon enrollment and will continue until the last day of the month in which the 60 day postpartum period has elapsed after the end of a pregnancy. Obstetric coverage for current ALL Kids members includes all prenatal care through 90 days postpartum and is billed as a bundled payment. Social Security numbers for the babies will not be required unless and until the child is born and applies for renewal.

Guidance: States may only require the SSN of the child who is applying for coverage. If SSNs are required and the State covers unborn children, indicate that the unborn children are exempt from providing a SSN. Other standards include, but are not limited to presumptive eligibility and deemed newborns.

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

Guidance: States should describe theircontinuous 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 SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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such individuals who meet the definition of lawfully residing, and may not cover a subgroup or only certain groups. In addition, states may not cover these new groups only in CHIP, but must also extend the coverage option to Medicaid. States will need to update their budget to reflect the additional costs for coverage of these children. If a State has been covering these children with State only funds, it is helpful to indicate that so CMS understands the basis for the enrollment estimates and the projected cost of providing coverage. Please remember to update section 9.10 when electing this option.

4.1- LR Lawfully Residing Option(Sections 2107(e)(1)(J) and 1903(v)(4)(A); (CHIPRA # 17, SHO # 10-006 issued July 1, 2010) Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) regarding lawfully residing to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following: A child or pregnant woman shall be considered lawfully present if he or she is: (1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641); (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission; (3) An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; (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) SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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of the INA (8U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 whohas 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 NorthernMariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under theimmigration 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, 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. AssurancesThe 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)) SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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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.

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) Superseded by ACA SPA 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 EnrollmentDescribe 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))

There are no public notice state laws regarding enrollment caps and waiting lists in CHIP. Due to insufficient state funds, ALL Kids initiated a waiting list beginning with all new enrollees who would have had an effective date October 1, 2003. Public and enrollee notices about the waiting list were issued during the month of September 2003 prior to the impact of the waiting list. On August 23, 2004, ALL Kids reopened enrollment and discontinued use of the waiting list.

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If during the year funds are not available at sufficient levels for coverage of children and funding is projected to be depleted before the end of the fiscal year, it is the State’s intent to place eligible children on a waiting list until adequate funding becomes available to resume enrollment. Alabama will provide public notice through press releases, written communication with stakeholders and stakeholder groups, presentations, and written communication from the program to all applicant families whose child(ren) is/are placed on the waiting list.

When a waiting list is implemented, the program has and will continue to receive new applications. These applications will be screened for Medicaid eligibility and then reviewed for ALL Kids eligibility. If a child is eligible for Medicaid, the child will be enrolled in Medicaid. Each family whose child is placed on the ALL Kids waiting list will be notified, by letter, of this placement. The notification letter will also contain information stating that the parent may wish to contact Medicaid if his situation changes and he believes that his child may be eligible for Medicaid. If the child remains on the waiting list for longer than three (3) months, the family will be periodically notified via letter that the child’s name is still on the waiting list.

If the State is using a waiting list, children will be enrolled on ALL Kids from the waiting list on a first on–first off basis as funding permits. When attrition has lowered program enrollment to a level at which there are sufficient state funds to re-open enrollment, children will be removed from the waiting list ( on a first on first off basis) and enrolled in ALL Kids. Children who are removed from the waiting list whose application information is greater than 90 days old will be asked to complete a form updating changes in information on their family size, income, and other points of eligibility. Upon receipt of the form, ALL Kids enrollment staff will evaluate the child’s eligibility for ALL Kids. Then, if eligible, either the child will be enrolled in ALL Kids or Medicaid and the family will be notified.

Children who have current enrollment in ALL Kids will be allowed to continue to renew their enrollment as long as they continue to meet all points of eligibility and have their renewal forms submitted and premium balances paid in full within 90 days after the date of termination. 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) SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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

4.3.3.2-ELList the public agencies approved by the State asExpress Lane agencies.

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

4.3.3.4-ELDescribe 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 SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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

The State of Alabama assures that through enrollment screening processes, children whose applications are considered to be eligible for medical assistance under the State Medicaid plan will be referred for assistance under the appropriate plan. Additionally, ALL Kids eligibility staff query the Medicaid eligibility system to ensure applicants are not currently on any Medicaid program. All applications request the parent/guardian to provide the names and addresses of their employers. Eligibility staff screen all applications to ensure applicant children are not currently covered under group health insurance and have not voluntarily terminated group coverage within the last three months. In an effort to further minimize crowd-out, ALL Kids receives a daily “error report” which indicates children who have current BCBS health insurance or have terminated a BCBS policy within the last three months. In addition, quality assurance reviews are conducted on a sample of ALL Kids enrollees. Redetermination is completed every 12 months.

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

When a child’s application is reviewed by ALL Kids and determined to be eligible for Medicaid, ALL Kids enrolls the child in Medicaid. Because a joint application is used, no additional form is required to be completed. Parents are notified by ALL regarding this determination

4.4.3. children found through the screening process to be ineligible for Medicaid are SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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enrolled in CHIP.(Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4)) ALL Kids and Medicaid have a joint eligibility and enrollment system. When a Medicaid enrollment worker determines that a child is ineligible for Medicaid and eligible for ALL Kids, the worker enrolls the child in ALL Kids. Coverage is based on the application receipt date at the Medicaid office or the child’s last date of Medicaid or ALL Kids coverage. ALL Kids staff work very closely with the Medicaid central office and Medicaid enrollment workers to ensure that the policies and procedures of both agencies reflect the agencies’ desires for seamless transitions between the two agencies.

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) This section is superseded by ACA SPA 4.4.4.1. (formerly 4.4.4.4) If the State provides coverage under a premiumassistance 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 Statewho are American Indian and Alaska Native. (Section2102(b)(3)(D)) (42CFR 457.125(a))

The State of Alabama assures the provision of child health assistance to targeted low-income children in the State who are American Indians (as defined in section 4(c) of the Indian Health Care Improvement Act, 25 U.S.C. 1603(c)). As Stated in section 4.1, the ALL Kids program will provide Statewide coverage. No ALL Kids enrollee identified as being an American Indian will be charged a premium or co-pay. This policy extends to all children who identify themselves as an American Indian children whether they are a member of a federally recognized tribe or one of the eight state-only recognized tribes. Representatives from the Poarch Band of Creek Indians (the only federally recognized Tribe in Alabama) have assisted in the development of ALL Kids PLUS. Tribal children will have access to PLUS services.

CHIP staff meet and coordinate regularly with the Alabama Commission on Indian Affairs to ensure that Native American Children are identified and enrolled in ALL Kids. Additionally, a Native American was hired under a one-year contract to consult with ALL Kids staff and develop a comprehensive strategy to outreach to Native American children. 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. SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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

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

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

Section 5. Outreach and Coordination

5.1. (formerly 2.2)Describe the current State efforts to provide or obtain creditable health coverage for uninsured children by addressing sections 5.1.1 and 5.1.2.(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):

In Alabama, thanks to outreach efforts of a variety of public and private agencies and organizations, there is a high awareness level of children’s health insurance programs and their eligibility requirements. Over one-fourth of children under the age of 19 in Alabama are covered by Medicaid or ALL Kids. The programs are reaching children who might not otherwise have access to the health care they need.

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Prior to CHIP, the Medicaid Program was the only public health insurance program for children in Alabama. Health services are provided in Alabama to uninsured and Medicaid enrolled children by private physicians, the 67 Alabama Department of Public Health (ADPH) county health departments, 16 primary care centers (including Federally Qualified Health Centers), two children’s hospitals (The Children’s Hospital of Alabama and Women’s and Children’s Hospital at the University of South Alabama) school health nurses, and one Indian Health Service Clinic. In addition to the two children’s hospitals, Alabama Department of Rehabilitation Services, Children’s Rehabilitation Services (CRS) provides specialty care to uninsured and Medicaid enrolled children with special health care needs. As lead agency for Alabama’s Early Intervention System, this agency coordinates services for infants and toddlers eligible for IDEA (Individuals with Disabilities Education Act), part C. This section describes the current efforts made by the ADPH to provide health care services, and to identify and enroll uncovered children in the Medicaid and ALL Kids programs. This section also describes the efforts made by CRS, the Alabama Medicaid Agency, the Alabama Department of Human Resources, and the Alabama Department of Mental Health and Mental Retardation to identify and enroll all uncovered children who are eligible to participate in the Medicaid and ALL Kids programs.

Alabama Department of Public Health As the CHIP lead agency, the ADPH is actively involved in all aspects of identification and enrollment of children who are eligible to participate in public health insurance programs and health insurance programs that involve public-private partnerships. Activities include the creation, publication, and distribution of marketing materials, management of the ALL Kids enrollment process, and targeted outreach activities for specific populations such as faith-based organizations, etc. The Alabama Department of Public Health provides some direct as well as support patient care for uninsured and Medicaid enrolled children and adolescents. Direct services for this population include: preventive child health services (well-child check-ups), prenatal services, Women Infants and Children Supplemental Nutrition [WIC] program services, preventive health education, immunizations, and Family Planning program services. Support services include case management services, the provision of information and referral via toll-free telephone lines, and laboratory services. These services are funded through federal Title V Maternal and Child Health Block Grant funds, federal Title X Family Planning program funds, federal WIC Program funds, Medicaid program reimbursements, federal immunization funds, state legislative appropriations, some local government appropriations, and a small amount of patient fee revenue. A variety of the above direct and support services are provided within ADPH county health departments. In fiscal year 2001, 34,664 children (birth through age 18 years) received health services in local county health departments. (This number excludes single service patients [STD-only, Immunization-only, WIC-only].) The Alabama Department of Public Health is the state’s Title V agency. Additionally, there are approximately 512 school health nurses, R.N.s and L.P.N.s, (working under the auspices of the ADPH, private hospitals, the Alabama State Department of Education, and/or local education agencies) in the state who provide a variety of health screening services, primary care and SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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emergency services, Medicaid/ALL Kids enrollment facilitation, etc.

Income assessments are performed on all patients enrolled in ADPH clinics. The income assessments are reviewed for possible Medicaid eligibility. Beginning in FY 1991, Medicaid eligibility workers were out-stationed in health departments and other health care facilities to accept applications and complete Medicaid eligibility determinations at the time of health visits. A streamlined, four-page expanded Medicaid eligibility form, which was implemented in FY 1991, has been revised into a joint application with CHIP and the Alabama Child Caring Foundation (ACCF) and is available at county health departments. Out-stationed Medicaid eligibility personnel currently assist patients in completing the forms and data is put into an automated Medicaid system on-site. Final determination for Medicaid can then be made immediately. If the children appear to be ALL Kids or ACCF eligible the application is forwarded to the appropriate program.

New applications, as well as annual reviews of established patients, are assessed by ADPH intake staff and/or care coordinators for possible referral for medical assistance through Medicaid, ACCF, or SSI. When appropriate, staff assist families in completing the application forms, making appointments, and gathering medical information. Out-stationed Medicaid eligibility workers are based in many ADPH clinics, hospitals, and primary care centers across the state. Additionally, two Medicaid outstationed workers and a clerk are now located in the CHIP office who process many ALL Kids referrals. A third worker will be added in FY 2003.

Cross training sessions with staff at many levels has improved interagency communication at the community level.

In order to provide additional outreach, the ADPH operates two toll-free telephone lines for use by the general public. The toll-free telephone lines (established prior to the implementation of CHIP and continued to the present) are known as Healthy Beginnings and Info Connection. Two integral parts of the information provided to callers, via these telephone lines, are information on Medicaid, ALL Kids, and ACCF eligibility and referrals to health providers who accept Medicaid-eligible children and Medicaid-eligible pregnant women. Referral services provided by the Healthy Beginnings and Info Connection staff members are expanded through consultation supplied by a host of additional professionals located within the ADPH. The toll-free number for Healthy Beginnings is 1-800-654-1385. The Info Connection number is 1-800-545-1098. Both lines are operational 24 hours a day, seven (7) days a week; office hours are from 8:30 A.M. to 4:30 P.M. each week day. The Healthy Beginnings and Info Connection lines are publicized statewide through newspapers, television, posters, and pamphlets. Presentations regarding the lines are conducted statewide to various organizations and agencies. The numbers are also published in Alabama South Central Bell telephone books. Additionally, with the implementation of CHIP, the CHIP unit maintains two toll-free telephone lines (888-373-5437 for enrollment and eligibility issues and 877-774-9521 for administrative issues). Finally, in addition to the above efforts, ALL Kids, Medicaid, and the Alabama Child Caring Foundation have developed a joint application and renewal form for SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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use by all three programs. This enables families to be screened for eligibility for all three programs and facilitates referrals and timely enrollment in the appropriate program.

Alabama Department of Economic and Community Affairs (ADECA) ADECA notifies the ALL Kids regional staff when a plant or large business plans to close in the near future. ALL Kids regional staff present ALL Kids information and materials at employee meetings prior to the plant/business closing. In order to prevent gaps in health insurance coverage for the children of the employees of the plant/business, an ALL Kids policy was developed which provides for beginning ALL Kids coverage (for eligible children) the day after employer sponsored coverage ends if an application is received by the ALL Kids enrollment unit within 30 days after the plant/business closing.

Alabama Department of Rehabilitation Services Children’s Rehabilitation Service Children’s Rehabilitation Service (CRS) also has coordination agreements with the Alabama Medicaid Agency. (These contracts existed prior to CHIP and have continued to be in effect.) The Alabama Medicaid Agency contracted with CRS for the provision of specialty medical services, specialized therapy (such as physical, occupational, speech, etc) services, and case management services to children with special health care needs. With the implementation of ALL Kids, CRS clinics were added as preferred providers under the ALL Kids basic benefits package and the ALL Kids PLUS package.

New applications, as well as annual reviews of established patients, are assessed by CRS intake staff and/or care coordinators for possible referral for medical assistance through Medicaid, ALL Kids, ACCF, or SSI. When appropriate, staff assist families in completing the application forms, making appointments, and gathering medical information. Joint Medicaid/ALL Kids/ACCF eligibility forms are available in all CRS offices and clinics. As in the ADPH, cross training sessions with staff at many levels has improved interagency communication at the community level. Medicaid and ALL Kids information and outreach brochures and posters are available in every CRS office throughout the state.

Additionally, like the ADPH, CRS operates toll-free telephone lines for use by the general public. One line is operated at the state level in Montgomery and additional lines are located in each CRS district office. An integral part of the information provided to callers, via these telephone lines, is Medicaid, ALL Kids, and ACCF eligibility and referral information. CRS and Early Intervention (EI) have both completed database matches with ALL Kids files to identify children known to both programs. CHIP staff have participated in many staff trainings throughout the state to assist CRS and EI staff in outreach for ALL Kids, Medicaid, and ACCF.

Division of Early Intervention As the lead agency for Alabama’s early intervention system for infants and toddlers with SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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developmental disabilities and their families, this unit provides a toll free Child Find telephone number for use by the general public and primary referral sources. Additional efforts for coordination are described in the PLUS sections of this document.

Medicaid Agency The Alabama Medicaid Agency has 135 eligibility workers in over 170 locations to enroll children eligible for SOBRA Medicaid whose the family’s income is at or below 100 percent of FPL (for children born after September 30, 1983) or 133 percent of the FPL (for children through age five). With the implementation of CHIP, 23 workers were added throughout the state. In March, 2002, two eligibility workers and a clerk were housed in the ALL Kids central office to review applications referred from the ALL Kids eligibility workers. In addition to the CHIP office, these workers are located in places children are likely to go to receive health care - - county health departments, Federally Qualified Health Centers and hospitals. Because workers are in the community, they can and do establish working relationships with public and private providers, social service agencies and others. For example, supervisors provide in- service training and education on Medicaid, ALL Kids, and ACCF eligibility to physicians, Head Start workers, day care centers, Human Resources staff and others. The Alabama Medicaid Agency also has 10 district offices located throughout the state that process applications for the elderly and the disabled population. The 80 eligibility workers and 20 supervisors advise applicants about other programs and refer the applicants to the proper office when they do not qualify for a disabled program. They also advise about programs for which other family members may be eligible. These district offices work closely with providers to keep them informed of all programs available through the Medicaid Agency.

Applications for Medicaid, ALL Kids, and ACCF are easily available to anyone who needs one. Applications are available not only from Medicaid workers but also at physicians’ offices, county offices of the Department of Human Resources and hospitals. All sources of the joint application (i.e., ADPH, CRS, etc.) allow a “mail-in” application process thereby allowing Medicaid to complete a phone interview instead of a face-to-face interview. Medicaid has a toll- free number for anyone to call to ask questions about Medicaid eligibility and find out where and how to apply. The number is 1-800-362-1504. Medicaid’s Web site contains information on Medicaid eligibility and is used by advocates to assist people who want to apply for Medicaid.

Through its Medical Care Advisory Committee and its Physicians Task Force, Medicaid receives guidance on ways to reach potential Medicaid eligibles. Medicaid staff regularly brief these groups, who represent both providers and consumers, on all facets of the Medicaid program, including eligibility. Both groups are kept informed of upcoming changes in the Medicaid program and encouraged to provide comments and suggestions. With welfare reform and the separation of Medicaid eligibility from eligibility for public assistance, the Alabama Medicaid Agency and the Department of Human Resources have developed new cooperative arrangements to assure that children in the state’s lowest income SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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families have access to Medicaid. Applications may be completed through the mail with a telephone interview, thus eliminating the need for a face-to-face contact. Currently DHR workers assess their clients to determine whether they might be eligible for any Medicaid, ALL Kids, or ACCF program. Workers help to complete forms, gather information and make appointments as necessary. However, the enrollment function for this Medicaid program will be transferred from DHR to the Medicaid Agency within the coming year.

Outreach occurs after the birth of an infant to a Medicaid recipient. Following the birth of each newborn whose mother is a Medicaid recipient, the Alabama Medicaid Agency sends the infant's parent or guardian a pamphlet on the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program as well as a pamphlet on immunizations. When children are enrolled in the SSI Program, they are automatically enrolled in the Medicaid Program. Additionally, a brochure is sent to parents/guardians of all new SSI eligible children encouraging them to participate in the EPSDT program. In addition to these efforts, social workers within the ADPH conduct patient recruitment as a part of their case management activities. These recruitment efforts are conducted through community presentations and professional relationships with other State and local agencies which serve mothers and children.

The Alabama Department of Human Resources and the Alabama Department of Mental Health and Mental Retardation also provide case management services for Medicaid children known to their agencies, in order to facilitate their enrollment in health services particularly mental health services through the Rehabilitation Option.

Through CHIP Phase I, the Alabama Medicaid Agency, working with the Alabama Department of Public Health, took several major steps to identify and enroll all uncovered children who were eligible to participate in this public health insurance program. New eligibility workers were hired and they, plus existing eligibility workers, were trained in CHIP eligibility criteria as well as other Medicaid eligibility criteria. These eligibility workers are outstationed in health departments, hospitals, community health centers, CHIP office, etc.

In order to streamline the CHIP/Medicaid enrollment process, the Alabama Medicaid Agency initiated continuous eligibility for all Medicaid children under the age of 19 years, on April 1, 1998. Continuous eligibility means that Medicaid enrolled children maintain their Medicaid coverage continuously for one year from enrollment or re-determination.

Additionally, numerous presentations, regarding CHIP, have been made by knowledgeable professionals who are members of the broad based CHIP Workgroup and CHIP staff. These presentations include addresses to education professionals, rural health groups, child care management agencies, parents of children with special health care needs, Indian Health Service staff, the general public, etc. Some specific activities include:

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Notice to all Medicaid providers News releases and camera-ready materials for newspapers Articles published in newsletters of health care provider associations–Medical Association of the State of Alabama, Alabama Hospital Association, Alabama Dental Association, and others Television commercials Radio spots Brochures have been distributed to date for outstationed Medicaid workers, public health workers, county human resources workers, Early Intervention Coordinating Councils, Mental Health Centers, family services centers, primary health care centers, hospitals, advocacy and professional organization, and in the school system, principles and guidance counselors. Brochures distributed at state meetings of Alabama Conference of Social Work, Medical Association, American Academy of Pediatrics-Alabama Chapter, Alabama Dental Association, Family Practice doctors, and others Satellite conferences to provide information about the basic ALL Kids Program and instruction in completing the application. Distribution of applications and brochures to all public school systems, local health departments, welfare offices, hospitals, community health centers, physician and dentist offices, pharmacies, WIC clinics, and family law attorneys, etc. Public forums for parents and advocates of CSHCC/N (Children with Special Health Care Conditions/Needs)

With specific regard to the Conception to Birth expansion and the RIM HSI, the ADPH will provide information to pertinent providers, hospitals and programs serving the target population residing in the counties in which the expansion is implemented.

In addition to the above, the state has engaged in the following particular activities to promote ALL Kids PLUS. Originally, it was anticipated that ALL Kids PLUS would involve four state programs, Children’s Rehabilitation Service, Early Intervention, Mental Health/Mental Retardation, and Civitan International Research Center Sparks Clinics. After conducting database matches, reviews of Pediatric Health History information, claims data, through mutual agreement, Sparks determined that their services were being adequately reimbursed through the ALL Kids basic benefit package. Therefore, attention was focused on the remaining three agencies. Since that time, CHIP has entered into discussions with the Alabama Institute for the Deaf and Blind with regard to becoming an ALL Kids PLUS provider. CRS has had an active contract for the provision of PLUS services since October, 2000 and has served as a valuable partner in establishing protocols for the identification of ALL Kids enrollees in need of PLUS services and the identification of current clients in need of insurance coverage.

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shown that this was not the most productive method of identification. Database matches were necessary as a first action to even identify ALL Kids enrollees who were being served by CRS. After this baseline was established, claims reviews were shown to be a more valuable mechanism in identifying children eligible for PLUS services than were chart reviews. This claims review revealed that a much smaller percentage of ALL Kids enrollees, than originally projected, were in need of services beyond those available in the basic benefits package. Program staff continually monitor feedback from providers and families regarding the need for additional services. This type of feedback and analysis has influenced the approaches that have been used with the other potential ALL Kids PLUS agencies. Through the activities of the regional ALL Kids staff, central office social work consultant, and customer service staff, ALL

Kids enrollees in need of these specialized services provided by ALL Kids PLUS agencies have been identified and referred as appropriate.

In August of 1999, the ADPH broadcasted a nationwide satellite conference to educate the provider community and other concerned individuals regarding ALL Kids PLUS. In addition, CHIP staff provided training on the PLUS program to CRS staff at regional meetings.

Alabama Department of Human Resources (DHR) The DHR has continued to partner with the ADPH to communicate ALL Kids information to their county staffs. They have provided initial and continuing updates to county DHR staff as well as provided periodic shipments of applications, posters, etc. The DHR has also assisted with outreach efforts through its childcare management agencies and facilitated communication with licensed child day-care homes and centers.

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

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

There is only one health insurance program for children in Alabama that resembles a public- private partnership. This program is known as the Alabama Child Caring Foundation (ACCF) and is a part of Blue Cross Blue Shield. The Alabama Child Caring Foundation provides limited ambulatory health insurance to low income, non-Medicaid/non-ALL Kids, uninsured children under the age of 19 years who remain full-time students through grade 12. The SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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program is funded through private donations and matching funds from Blue Cross Blue Shield. Outreach for this program is conducted through articles in Blue Cross Blue Shield publications and public service announcements in local newspapers, via television, and radio stations. The University of Alabama and Auburn University coaches’ television shows expressly advertise the Foundation. Case finding is conducted by school administrators, school nurses, day care operators, and others. Additionally referrals to the Foundation are received from the ALL Kids program, local offices of the ADPH, the Alabama Medicaid Agency, the Alabama Department of Human Resources, the Alabama Department of Industrial Relations Dislocated Workers program, individual health care providers, civic organizations, churches, Sunday School classes, other religious organizations, and from Foundation participants.

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.

The State of Alabama assures coordination with other public and private programs providing creditable coverage for low-income children. The SOBRA Medicaid program, ALL Kids, and the Alabama Child Caring Foundation have developed and use joint application and renewal forms.

All applications received by the ALL Kids enrollment unit are screened for Medicaid eligibility. When a child is identified by an ALL Kids enrollment worker as potentially eligible for Medicaid, the family’s application is sent to a Medicaid enrollment worker. Medicaid then processes it. As stated previously, two Medicaid enrollment workers and one clerical worker are physically located within the ALL Kids enrollment unit. This process also works in the reverse (applications are sent from Medicaid to ALL Kids).

When a child is identified by an ALL Kids enrollment worker as not potentially eligible for the Medicaid or ALL Kids but potentially eligible for the Alabama Child Caring Foundation (ACCF), the family’s application is sent to ACCF which then processes it and the opposite is also true.

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Because it is recognized that the eligibility and enrollment systems of these three programs are not as seamless as needed, ALL Kids employs a full time MSW staff person. This staff person has responsibility to assist families in overcoming obstacles related to eligibility, enrollment, claims, and referral for specialty services as needed. Additional responsibilities include development and maintenance of the ALL Kids policy manual.

In addition, the State coordinates with the ALL Kids PLUS authorizing agencies. See the previous section for a broader description of the collaboration.

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

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

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

5.3. StrategiesDescribe 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)

Phase I - Medicaid Expansion This portion of the outreach section, as it pertains to Phase I of Alabama’s Title XXI program, consists solely of efforts that were targeted toward Medicaid eligibles who were born after September 30, 1983 and who are under 19 years of age. There were four primary avenues through which outreach was conducted. These avenues were (1) the use of existing outreach approaches, (2) an initiative to improve communication with and services for the state’s rapidly expanding Hispanic population, (3) an increase in the number of Medicaid eligibility workers, and (4) coordination with the State Medical Association and physicians to educate physicians and their potentially eligible patients. Detailed information regarding these efforts is available from CHIP upon request.

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Phase II - ALL Kids Outreach for ALL Kids is conducted through coordinated Statewide and regional efforts and in each county through partnerships, contracts, and regional CHIP coordinators. These efforts consist of a three-pronged approach: (1) Statewide media campaigns and initiatives; (2) outreach conducted by multi-county regional workers and consultants; and, (3) outreach conducted through existing programs and agencies. The purposes of all of these activities is to build networks and coalitions of persons who can inform individuals about the availability of ALL Kids and what it has to offer, and assist individuals in completing application forms. Outreach is conducted by a variety of individuals and in a variety of settings. Each feature of the three-pronged outreach approach is described below:

• Statewide media campaigns and initiatives - The media campaigns focus on informing individuals about the availability of ALL Kids and what they have to offer as well as providing information regarding where applications or other information may be obtained. Additionally, ALL Kids staff attend a wide variety of association meetings and conferences to inform memberships of the availability of children’s health insurance. The staff have developed specialized outreach materials (from videos to informational brochures and flyers to specific handouts) for specific groups to meet their needs.

Staff have exhibited at booths and presentations to the Medical Association of the State of Alabama, Alabama Chapter of the American Academy of Pediatrics, Family Practice Physicians, Dentists, Social Workers, Department of Human Resources staff, Mental Health staff, Family Law Judges, Hospitals, Hospital auxiliaries, WIC staff, Public Health Staff, etc.

• Outreach conducted by multi-county regional workers and consultants – since the Spring of 2002, ALL Kids consultants have been and/are employed throughout the state, to disseminate information about the program to develop coalitions and networks of local residents to assist individuals in completing and submitting applications. These regional coordinators, their supervisory directors, and consultants are many times based in the county health departments but also utilize numerous off-site locales and alternative working hours. • Outreach conducted through existing programs and agencies - Information about CHIP, applications, and application assistance are available through existing child-related programs such as the Child Care Management Agencies and their targeted child day care centers, Food Stamps, Maternal and Child Health Block Grant Program clinics, WIC clinics, community health centers, Indian Health Services, school nurse programs, school counselor programs, Early Intervention programs, other social service agencies, etc. These programs and agencies have successful histories of serving the target population and the CHIP program utilizes their contact with this population to broaden outreach efforts. Dissemination of CHIP information to these entities has been facilitated since representatives of these agencies and programs served on the CHIP Advisory Council and

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continue to be in contact with CHIP as stakeholders. • With specific regard to the Conception to Birth expansion and the RIM HSI, the ADPH will provide information to pertinent providers, hospitals and programs serving the target population residing in the counties in which the expansion is implemented.

Phase III - ALL Kids PLUS Outreach for this special population is conducted primarily by the ALL Kids PLUS authorizing agencies. Outreach includes educating primary and specialty care physicians regarding ALL Kids PLUS, identifying and contacting children who may need PLUS services through reviews of agency rolls and possible reviews of the pediatric health histories (part of the application process), contact with community health centers, etc. Information about ALL Kids PLUS is incorporated into all publications and presentations.

In an effort to continually improve the ALL Kids PLUS, CHIP staff continue to meet with the ALL Kids PLUS participating agencies to identify and resolve any problematic areas and to recruit additional participating agencies. PLUS agencies assist the CHIP staff in developing contracts, performance standards, and procedures for ongoing monitoring and oversight of the ALL Kids PLUS program.

NOTE: The application form and other materials have been translated into Spanish. Additionally, the ALL Kids enrollment unit employs a Spanish-speaking staff member and a Hispanic consultant has been hired to develop a Hispanic outreach plan.

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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: Checkbox 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)))

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6.1.1.3. HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

The benefit package offered by the health maintenance organization with the largest insured commercial, non-Medicaid enrollment of covered lives was selected after several well attended public meetings where the benefits of the three benchmark plans were compared with the assistance of the insurers/administrators for the three plans. The benefit plan was altered slightly to make it more appropriate for children’s needs.

In addition to the ALL Kids basic benefits package, additional benefits may be available for enrollees who have special needs. These additional benefits are known as ALL Kids PLUS benefits and are only available as prescribed by ALL Kids PLUS authorizing agencies. These decisions regarding what benefits are provided, the requirements for their receipt, and the provision of the benefits is under the auspices of the PLUS authorizing state agencies. These state agencies are those with which CHIP has a contract for the provision of ALL Kids PLUS services, those agencies that ordinarily serve children with special health care conditions and needs, and which provide the matching funds for federal CHIP funding

The ALL Kids benefits plan is described in the ALL Kids Summary Plan Description (SPD), which is available upon request.The benefit package for enrollees in the CHIP Medicaid expansion will be identical to other children enrolled in comprehensive Medicaid categories.

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 SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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described in 42 CFR 457.430: • coverage of prescription drugs, • mental health services, • vision services and • hearing services.

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

The actuarial report must be prepared by an individual who is a member of the American Academy of Actuaries. This report must be prepared in accordance with the principles and standards of the American Academy of Actuaries. In preparing the report, the actuary must use generally accepted actuarial principles and methodologies, use a standardized set of utilization and price factors, use a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan, apply the same principles and factors in comparing the value of different coverage (or categories of services), without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used, and take into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage. (Section 2103(a)(2))

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))

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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 individualchild 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 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. Coverageof all benefits that are provided to childrenthat is the same as the benefits provided under the Medicaid State plan,including Early Periodic Screening, Diagnostic, and Treatment (EPSDT).

6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver.

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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. In the second amendment to the Alabama CHIP State Plan, ALL Kids PLUS was established which provided additional benefits for children with special health care conditions/needs. Attachment A contains a detailed description of the ALL Kids PLUS component of CHIP.

6.1.4.5. Coverage that is the same as defined by existing comprehensive state- based coverageapplicable only in New York, Pennsylvania or Florida.(under 42 CFR 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 coverage under one of the benchmark plans specified in 457.420, through the 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 in457.431 to determine actuarial equivalence.

6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Provide a sample of how the comparison will be done).

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

6.1.4.7. Other. (Describe) Comprehensive health coverage will be provided from conception to birth for those with family incomes up to and including 312% FPL, whose mothers do not have comprehensive coverage, and reside in select counties in Alabama (beginning in Montgomery, Macon and Russell). Coverage begins upon enrollment and extends only through delivery with the exception of bundled obstetrical benefits. Coverage for bundled obstetrical benefits begins upon enrollment and will continue until the last day of the month in which the 60 day postpartum period has elapsed after the end of a SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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pregnancy. For example, if a woman gives birth on June 26, benefits covered in the bundled package would end on August 31. The first day without coverage would be September 1. The date of enrollment may be as early as the first day of maternity- related service provision even if the application is completed a few days after the service is received. In other cases coverage will begin on the date the application is received by the CHIP office. The definition of comprehensive coverage includes coverage for obstetrical benefits. If a pregnant woman has other coverage but the other coverage does not include obstetrical benefits, then the other coverage would be considered non- comprehensive, regardless of any other benefits it insures. In this circumstance, the pregnant woman would meet the criterion for not having comprehensive coverage.

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

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

6.2. The State elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490) A description of the scope, amount and duration of services covered under ALL Kids and ALL Kids PLUS, as well as any exclusions and limitations can be found in the ALL Kids Summary Plan Description (SPD) which is available upon request. Health insurance benefits provided to conception to birth enrollees will be identical to the health insurance benefits provided to any pregnant ALL Kids enrollee. The date of enrollment may be as early as the first day of maternity-related service provision even if the application is completed a few days after the service is received. In other cases coverage will begin on the date the application is received by the CHIP office. Comprehensive coverage will end upon the end of the pregnancy. Prenatal care, labor and delivery and postpartum care are paid using a bundled payment which extends into the postpartum period. In geographic areas in Alabama where CHIP unborn coverage is available, coverage for bundled obstetrical benefits begins upon enrollment and will continue until the last day of the month in which the 60 day postpartum period has elapsed after the end of a pregnancy. For example, if a woman gives birth on June 26, benefits covered in the bundled package would end on August 31. The first day without coverage would be September 1.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Guidance: See guidance for Section 6.1.4.1 for 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 the box below.

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

Guidance: Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or rehabilitative service may be provided, whether in a facility, home, school, or other setting, if recognized by State law and only if the service is: 1) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as prescribed by State law; SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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2) performed under the general supervision or at the direction of a physician; or 3) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

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

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

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

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

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

6.2.31. Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28)) Transplantation Services Emergency and Urgent Care Services Skilled Nursing Services Vision Services 6.2-DC Dental Coverage(CHIPRA # 7, SHO # #09-012 issued October 7, 2009) The State will provide dental coverage to children through one of the following. Please update Sections 9.10 and 10.3-DC when electing this option. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5)):

6.2.1-DC State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT6) codes are included in the dental benefits: 1. Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must follow periodicity schedule) 2. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes: D1000-D1999) (must follow periodicity schedule) 3. Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999) 4. Endodontic (i.e., root canals) (CDT codes: D3000-D3999) 5. Periodontic (treatment of gum disease) (CDT codes: D4000-D4999)

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6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200-D6999) 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999) 9. Emergency Dental Services

ALL Kids utilizes the BCBS of Alabama preferred Dental Network. Reimbursement for services delivered to ALL Kids' enrollees is paid based on the preferred dental network fee schedule. All network dentists agree to accept this as payment in full, with the exception of enrollee co-pays (no copayments on preventive or diagnostic services).

When costs are expected to exceed $1500 for a calendar year, ALL Kids utilizes a prior authorization process to ensure medically necessary services are provided. Costs associated with diagnostic and preventive services are excluded from this $1500 threshold. The amount is calculated by totaling the amount paid in dental claims minus the amount paid for preventive and diagnostic dental services.

If an enrollee is in need of dental services beyond $1500 in a calendar year, providers are instructed to submit a predetermination request to BCBS. BCBS reviews all provider requests to determine dental necessity of services and ALL Kids provides final approval to pay for services exceeding $1500. Providers are familiar with this process and dentally necessary services are provided in a timely manner regardless of the time of year. There is no unnecessary carry-over of services that need immediate attention.

If a family would like to appeal the BCBS/ALL Kids decision regarding the application of “medically necessary,” there is an appeals process which is consistent with the requirements of 42 CFR 457.1160 (b) and in compliance with state laws, the Security Act of 1974 (ERISA) and all other applicable regulations of the Department of Labor Procedures. 6.2.1.1-DC Periodicity Schedule. The State has adopted the following periodicity schedule: State-developed Medicaid-specific American Academy of Pediatric Dentistry Other Nationally recognized periodicity schedule Other (description attached)

6.2.2-DC Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR 457.420)

6.2.2.1-DC FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked, attach copy of the dental supplemental plan benefits description and the applicable CDT7 codes. If the State chooses to provide supplemental

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services, also attach a description of the services and applicable CDT codes)

6.2.2.2-DC State employee coverage; (Section 2103(c)(5)(C)(ii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2.2.3-DC HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2-DS Supplemental Dental Coverage- The State will provide dental coverage to children eligible for dental-only supplemental services. Children eligible for this option must receive the same dental services as provided to otherwise eligible CHIP children (Section 2110(b)(5)(C)(ii)). Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, and 9.10 when electing this option.

Guidance: Under Title XXI, pre-existing condition exclusions are not allowed, with the only exception being in relation to another law in existence (HIPAA/ERISA). Indicate that the plan adheres to this requirement by checking the applicable description.

In the event that the State provides benefits through a group health plan or group health coverage, or provides family coverage through a group health plan under a waiver (see Section 6.4.2.), pre-existing condition limits are allowed to the extent permitted by HIPAA/ERISA. If the State is contracting with a group health plan or provides benefits through group health coverage, describe briefly any limitations on pre-existing conditions. (Formerly 8.6.)

6.2- MHPAEASection 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).

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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)

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 provideany 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

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Guidance: If the State child health plan does not provide EPSDT consistent with Medicaid statutory requirements at sections 1902(a)(43) and 1905(r) of the Act, please go to Section 6.2.3- MHPAEA to complete the required parity analysis of the State child health plan.

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

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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))

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- SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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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 providedthe 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 benefitlimitations under the State child health plan as a result of the parity analysis are also made in Section 6.2.

6.2.3- MHPAEAIn 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.

Benefit Classification Standards Used Inpatient Inpatient benefits are applied per the benefit plan to a registered inpatient bed patient in a hospital. Outpatient Outpatient benefits are applied per the benefit plan to a patient who is not a registered inpatient bed patient of a hospital. Pharmacy Pharmacy benefits are applied per the benefit plan and evidence based clinical criteria for use of medication, regardless of behavioral health or medical diagnosis. Emergency Services covered in connection with a medical condition that occur suddenly and without warning with symptoms which are so acute and severe as to require immediate medical attention.

6.2.3.1.1 MHPAEAThe State assures that:

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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.

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 SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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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 toall 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))

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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 anattachment to the State child health plan.

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

Less than 1/3

At least 1/3 and less than 2/3

At least 2/3

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

Less than 1/3

At least 1/3 and less than 2/3

At least 2/3

Guidance: If an aggregate lifetime limit is applied to less than one-third of all medical/surgical benefits, the State may not impose an aggregate lifetime limit on any mental health or substance use disorder benefits. If an annual dollar limit is applied to less than one-third of all medical surgical benefits, the State may not impose an annual dollar limit on any mental health or substance use disorder benefits (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 anannual or lifetime SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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limit.

6.2.4.3.2.1- MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least1/3 and less than 2/3 of all medical/surgical benefits, the State assures the following (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 with42 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

6.2.5- MHPAEADoes 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: )

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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 QTLsto 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- MHPAEAWithin each classification of benefits in which the State applies a type of QTL on any mental health or substance use disorder benefits, theState 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 resultsas anattachment to the State child health plan.

6.2.5.3- MHPAEAFor each type of QTL applied to any mental health or substance use disorder benefits within a given classification,does the Stateapply the same type of QTL to “substantially all”(defined as at least two-thirds) of the medical/surgical benefits within the SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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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- MHPAEAFor 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))

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 SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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CFR 457.496(d)(3)(i)(B)(2))

Non-Quantitative Treatment Limitations

6.2.6- MHPAEAThe 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 – MHPAEAThe 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 surgicalbenefits 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:

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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 Blue Cross Blue Shield of Alabama; New Directions (Behavioral Health Benefits Manager for BCBS); Prime Therapeutics (Pharmacy Benefits Manager for BCBS)

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

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Blue Cross Blue Shield of Alabama; New Directions (Behavioral Health Benefits Manager for BCBS); Prime Therapeutics (Pharmacy Benefits Manager for BCBS)

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)) (42 CFR 457.1005 and 457.1010)

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

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

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

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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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))

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 SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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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 # 10-002issued 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? Yes No

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

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6.4.3.1.1-PAProvide an assurance that the qualified employer- sponsoredinsurance 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-PADescribe 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-PADescribe 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-PAProvide an assurance that the waiting period for children in premium assistance is the same as for those children in direct coverage (if State 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-PADescribe the State’s process for ensuring parents are permitted to SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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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-PADescribe 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-PADescribe the plan to establish an employer-family premium assistance purchasing pool.

6.6.3.5.2-PAProvide 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-PAProvide 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 informed of the choices for child health assistance or through the receipt of premium assistance subsidies (Section 2105(c)(10)(K)).

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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

Section 7. Quality and Appropriateness of Care

Guidance: Methods for Evaluating and Monitoring Quality- Methods to assure quality include the application of performance measures, quality standards consumer information strategies, and other quality improvement strategies.

Performance measurement strategies could include using measurements for external reporting either to the State or to consumers and for internal quality improvement purposes. They could be based on existing measurement sets that have undergone rigorous evaluation for their appropriateness (e.g., HEDIS). They may include the use of standardized member satisfaction surveys (e.g., CAHPS) to assess members’ experience of care along key dimensions such as access, satisfaction, and system performance.

Quality standards are often used to assure the presence of structural and process measures that promote quality and could include such approaches as: the use of external and periodic review of health plans by groups such as the National Committee for Quality Assurance; the establishment of standards related to consumer protection and quality such as those developed by the National Association of Insurance Commissioners; and the formation of an advisory group to the State or plan to facilitate consumer and community participation in the plan.

Information strategies could include: the disclosure of information to beneficiaries about their benefits under the plan and their rights and responsibilities; the provision of comparative information to consumers on the performance of available health plans and providers; and consumer education strategies on how to access and effectively use health insurance coverage to maximize quality of care.

Quality improvement strategies should include the establishment of quantified quality improvement goals for the plan or the State and provider education. Other strategies include specific purchasing specifications, ongoing contract monitoring mechanisms, focus groups, etc.

Where States use managed care organizations to deliver CHIP care, recent legal changes require the State to use managed care quality standards and quality strategies similar to those used in Medicaid managed care.

Tools for Evaluating and Monitoring Quality- Tools and types of information available include, HEDIS (Health Employer Data Information Set) measures, CAHPS (Consumer Assessments of Health Plans Study) measures, vital statistics data, and SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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State health registries (e.g., immunization registries).

Quality monitoring may be done by external quality review organizations, or, if the State wishes, internally by a State board or agency independent of the State CHIP Agency. Establishing grievance measures is also an important aspect of monitoring.

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.

Guidance: The State must specify the qualifications of entities that will provide coverage and the conditions of participation. States should also define the quality standard they are using, for example, NCQA Standards or other professional standards. Any description of the information strategies used should be linked to Section 9. (Section 2102(a)(7)(A)) (42CFR 457.495)

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. (Section 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.) The State utilizes the expertise within the University of Alabama at Birmingham (UAB) School of Public Health in the implementation of the assessment of the ALL Kids program. Quality and appropriateness of care is assessed through the use of surveys such as a new enrollee survey, a continuous enrollee survey, and a disenrollee survey. Both process measures as well as outcome measures are considered when assessing the quality and appropriateness of care. CHIP also reviews claims data for quality assessment. Among the items used in tracking are the use of several claims data indicators such as whether or not children truly have a "medical home"; how well they are adhering to the recommended scheduled well-child exams; whether or not they are appropriately immunized; whether or not non-trauma based emergency room use is going down; how referrals are being made and if specialty care and related services are being received; and, patterns of prescription drug use. The State is also considering using other databases that can provide general indicators of child health and well-being such as the State’s immunization registry, adolescent pregnancy rates and health care utilization patterns identifiable off birth certificates, and the results of child death review efforts. Alabama monitors customer/patient/provider satisfaction through the use of surveys and informal communications with families, advocacy groups, and providers.

In addition to these monitoring strategies, the State assures access to care through monitoring of the provider network and benefit package design. Program staff are actively involved in identifying new providers for the ALL Kids network and have been particularly involved in the addition of pediatric dentists, primary care nurse practitioners, community mental health centers and emergency transportation providers. Geographic distribution of providers is SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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monitored and is crucial when decisions regarding vendor choice are made.

The ALL Kids benefits package requires preauthorization only for hospitalization services. Therefore, access to all primary care providers and specialists is open to all enrollees without referral. Claims data are monitored by program staff to ensure quality and appropriateness of care. In addition, the State employs a masters level social worker to assist families who are experiencing difficulties accessing necessary services due to benefit structure or provider geographic availability. This staff member works closely with case managers at the vendor to identify areas in need of attention and provides the State with recommendations for benefit plan adjustment and/or provider network issues.

The ALL Kids PLUS program coordinates the evaluation of quality and appropriateness of care with the ALL Kids PLUS authorizing agencies and CSHCC/N advocacy groups through collaboration with stakeholders. It is also anticipated that an evaluation of ALL Kids PLUS may become part of the UAB evaluation in the future.

7.1.1. Quality standards . Performance measurement

7.1.2 (a) CHIPRA Quality Core Set

7.1.2 (b) Other The State ensures quality through contracted performance measures. These measures have been adapted in conjunction with the standards recommended by the AAP.

7.1.3. Information strategies Vendors are required to provide key health indicators information.

7.1.4. Quality improvement strategies

The performance guarantees and provider recoupment policy were included in the RFP and are included in the contract with the health plan.

Guidance: Provide a brief description of methods to be used to assure access to covered services, including a description of how the State will assure the quality and appropriateness of the care provided. The State should consider whether there are sufficient providers of care for the newly enrolled populations and whether there is reasonable access to care. (Section 2102(a)(7)(B))

7.2. Describe the methods used, including monitoring, to assure: (Section 2102(a)(7)(B)) (42CFR 457.495) SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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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)) Access is monitored through a number of methods including the following: Periodic review of the number and types of providers by county Quarterly review of claims data Quarterly review of new enrollee, continuous enrollee, and disenrollee survey data Feedback from families via telephone, e-mail, and postal service mail Feedback from providers

Further, the state uses claims data to monitor well-baby care as is described in 7.1.

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)) Access is monitored through a number of methods including the following: Quarterly review of claims data Quarterly review of new enrollee, continuous enrollee, and disenrollee survey data Feedback from families via telephone, e-mail, and postal service mail Feedback from providers Feedback from the CHIP Social Work Consultant

Further, the state uses claims data to monitor emergency room use as is described in 7.1.

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)) Access is monitored through a number of methods including the following: Periodic review of the number and types of providers by county Quarterly review of claims data Quarterly review of new enrollee, continuous enrollee, and disenrollee survey data Feedback from families via telephone, e-mail, and post service mail Feedback from providers Feedback from CSHCC/N advocates and ALL Kids PLUS providers

The ALL Kids PLUS network includes State agencies that serve children with special health care needs/conditions and that contract with CHIP to provide state matching funds for ALL Kids enrollees who use PLUS services. Currently, Children Rehabilitation Services is the only active PLUS program. The PLUS agency provides ALL Kids children with an individual case manager who will monitor access to specialists and treatment.

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In general, the Medicaid standards will be used to establish qualifications for ALL Kids PLUS case management staff. All case management staff will meet specific qualifications, including education, training and appropriate credentialing which will be established by the participating agencies.

In most circumstances, the agencies’ delivery systems are discrete and clear which program provides services for specific conditions. However, where there is potential for overlap in responsibilities, the determination of which agency will provide case management will be done based on the needs of the child with input from the family and by determining what is in the best interest of the child. The agencies using the case management process, will coordinate with each other, the child, the family, and the care providers in determining if a change in case management is needed.

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)) Exigent medical circumstances may require more rapid response according to the medical needs of the patient. The health plan vendor has policies in place to assure that prior authorization of health services are completed in accordance with state law or regulations promulgated by the Department of Labor. CHIP staff receive feedback from providers and enrollee families if time periods are exceeded. All prior authorization of health services is in accordance with state laws. Children enrolled in a Medicaid expansion are subject to the same prior authorization policies to which children enrolled in Medicaid’s other full service children’s programs are subject.

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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)) There will not be any cost sharing of any type for families who are Native Americans or Alaskan Natives. There will also not be any cost sharing of any type for families whose children are enrolled in a CHIP Medicaid expansion. For all other families cost sharing will be as follows in 8.2.1. and 8.2.3.:

8.2.1. Premiums:

There are three (3) categories of enrollees: No Fee (Native Americans and Alaskan Natives). Low-Fee (children with family incomes from the base (above 141% FPL) up to and including 156% FPL), and Fee (children with family incomes greater than 156% FPL up to and including 312% FPL). There is no cost sharing for children in the No Fee group. There is a $52 premium per child, per year for children in the Low-Fee group. There is a $104 premium per child, per year for children in the Fee group. Premiums can be paid in one payment or in SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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periodic payments (weekly, monthly, quarterly…) throughout the year. A family’s total premium payments are limited to three times the individual premium rate (i.e. $156 or $312 depending upon the income level of the family). Enrollment data systems do not allow for a family to be billed in excess of these amounts. Outstanding premium balances may be waived at the State’s discretion for applicants/enrollees living or working in FEMA or Governor declared disaster areas.

Premiums will not be charged to those enrolled in the Conception to Birth expansion.

8.2.2. Deductibles: None 8.2.3. Coinsurance or copayments:

There are no copayments for preventive services. The only permitted copayments are:

Fee Group Low Fee Group Copayments Copayments (for (for Children Children with with Incomes Incomes up to and >156% FPL up including 156% to and including Service FPL) 312%)

Dental $5/visit $20.00/visit

Doctor’s office visits $3/visit $13.00/visit

Behavioral Health office visits $3/visit $13.00/visit

ER Services $6/facility charge $60.00/facility charge

Inpatient Services (Hospital) $200/confinement $200/confinement

Non-Emergency ER Services $6/visit $60.00/visit

Allergy Testing $6/lab visit $17.00/lab visit

Allergy Treatment $3/visit $12/visit

Ambulance $6/occurrence $100/occurrence

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Mental and Nervous (Inpatient) $200/confinement $200/confinement

Outpatient Surgical Facility $6/visit $100/visit

Substance Abuse (Inpatient) $200/confinement $200/confinement

X-ray (Outpatient Facility) $6/total x-rays in 1 visit $65/total x-rays in 1 visit

Therapies (Physical, Occupational, Speech) $3/visit $13/visit

Routine Eye Exam $3/visit $13/visit

$3/frames Eye Glasses and/or lenses $13/ frames and/or lenses

Chiropractic visits $2/visit $5/visit

In addition, a Generic Plus pharmacy benefit became effective October 1, 2012 for children in both the low fee and fee groups. Prescription drugs are divided into two groups: generic and preferred brands. The designation “preferred” is assigned by the third party administrator. The copayment schedule is as follows: Fee Group Copayments (for Children Low Fee Group with Incomes Copayments (for Children >156% FPL up with Incomes up to and to and including including 156% FPL) 312%) Generic $1.00 $5.00 Preferred Brands $5.00 $25.00

For those enrolled in the Conception to Birth expansion, copayments will be assessed for the services and pharmacy as indicated in the above tables. Copayment amounts will be based on family income as noted below:

0% FPL up to and including 146% FPL - No copayment requirements From >147% FPL up to and including 156% FPL - assigned to the Low Fee copayment structure From >156% FPL up to and including 312% FPL – assigned to the Fee Group copayment structure 8.2.4. Other:

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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 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)) All enrollees are provided with coverage and cost-sharing information at initial enrollment through mailed documents. Additionally, this information is available online. All enrollees are notified of cost-sharing changes through letters mailed directly to the residence addresses on file with CHIP. In addition all stakeholders, including provider organizations/associations and state agencies, are notified by letter or other appropriate means of communication (i.e. email, fax notifications, and/or meetings) when changes are made to cost-sharing requirements. CHIP staff and customer service representatives are trained to discuss cost-sharing requirements with families, including premiums, copayments, and the annual out of pocket expenses limit.

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)) SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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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: inpatient, outpatient, prescription drugs, emergency room) Inpatient, outpatient, prescription drugs and emergency room

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 SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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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, theState 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 anattachment to the State child health plan.

8.4.7- MHPAEAFor each type of financial requirement applied to any mental health or substance use disorder benefits within a given classification,does the Stateapply 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- MHPAEAFor 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))

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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))

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))

Alabama ensures that the annual aggregate cost-sharing for a family does not exceed five percent (5%) of a family’s income as is required by Section 2103(3)(B) of Title XXI. In addition, cost sharing, both premiums and copayments are in compliance with CHIP regulations.

There is minimal cost sharing for families, other than Native Americans and Alaskan Natives who have no cost sharing. No family is charged for more than three (3) premiums even if the family has more than three children.

To protect families against excessive medical expenses and comply with the statutory limit of no more than five percent of family income being expended on cost sharing expenses, families will be notified in writing, at initial enrollment and renewal, of the annual out of pocket maximum. Families are informed of this policy through educational literature. Also, CHIP staff and partners are trained to educate families about the limit on out of pocket expenses. Families are encouraged to keep receipts for all copayments and premiums so that once the out of pocket maximum is reached they will have the necessary documentation to stop cost-sharing. If a family reaches this limit and notifies the ALL Kids program, ALL Kids will review the case and if the limit has been reached new insurance cards will be issued stating that the child(ren) are not subject to further co-pays for the coverage period.

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) If a child is identified on an application as an American Indian, the enrollment worker SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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automatically places the child in the no-fee category if the child becomes enrolled. Therefore the insurance vendor sends an insurance card, to the family, which indicates that the child is not subject to any co-pays.

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)) Superseded by ACA SPA Guidance: Section 8.7.1is 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 belowof 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))

ALL Kids has an annual premium for those in cost sharing categories. Upon enrollment, families are notified, by letter, that premiums are due. Enrollees have the entire 12-month coverage period to pay premium balances and receipt of benefits is not contingent upon payment of premiums. Current enrollees are not terminated for non-payment of premium during the 12-month coverage period. At one month, four months, seven months, and 10 months, families are notified of outstanding premium balances. They are notified, every notice for past-due premiums and cost-sharing, that, in most circumstances, premiums must be paid in full for ALL Kids coverage to be renewed. If a renewal application is received within 90 days past the coverage end date (and the premium is paid no later than 90 days past the coverage end date), enrollees may renew with no lapse in coverage.

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))

The amount of family income written on the renewal form is reviewed by enrollment workers at the time of renewal. If it is known to ALL Kids that a family is experiencing financial difficulty, the ALL Kids Social Work Consultant and/or ALL Kids Regional staff may assist

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the family in locating assistance for premium payment. Non-payment of premiums is forgiven if the family provides proof of bankruptcy status during the enrollment period or if the family has been affected by disaster events (living or working in FEMA or Governor declared disaster areas at the time of a disaster event).

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)) At the time of renewal, if the family’s income has dropped but is still above the Medicaid eligibility level, if the decision is made to forgive the unpaid premium(s), the child is renewed and placed in the appropriate ALL Kids category. If a family’s income has dropped below the ALL Kids eligibility, the child’s application is reviewed for Medicaid eligibility and, if the child meets all eligibility requirements, s/he is enrolled in Medicaid.

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))

This type of grievance is handled in the same impartial manner in which other grievances are handled as described in Attachment A.

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, copayments, 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) SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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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))

1. The number of low-income (<200% FPL), uninsured children in AL will be reduced each year.

2. Given available funding, the number of low income (between the Medicaid eligibility upper income levels and 200% FPL), children enrolled in ALL Kids will be maintained at at least 50,000 (current enrollment) at any given time.

3. The number of low-income children (incomes in the Medicaid income eligibility ranges) enrolled in SOBRA Medicaid will be maintained at at least 300,000.

4. Enrollment in ALL Kids will result in more children having a medical home.

5. Enrollment in ALL Kids will result in a higher usage of preventive care.

6. Specialty services beyond the basic ALL Kids coverage package will be available for ALL Kids enrolled children with special health care needs.

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)) 1. Performance Goals for Objective 1: a. The number of low-income uninsured children in AL will be reduced by 1% each year until the number of low-income uninsured children is no larger than 10% of the children in the state. b. A tracking system will be established by April 2004, which will track applicants referred among ALL Kids, SOBRA Medicaid, and the Alabama Child Caring Foundation.

2. Performance Goals for Objective 2

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a. The percentage of families who do not renew their children’s ALL Kids coverage due to a financial barrier (owing past premiums) will not be more than 3% annually. b. A higher percentage of families with ALL Kids enrolled child(ren), report that financial barriers to accessing care have been reduced since enrollment in ALL Kids in comparison to the time before enrollment in ALL Kids. c. Plans which target outreach activities toward specific populations: (adolescents, Native Americans, and faith-based organizations) will be developed by October, 2002. d. Plans which target outreach activities toward specific populations: (adolescents, Native Americans, and faith-based organizations) will be implemented each year beginning with FY 2003. e. Plans which target outreach activities toward Hispanics, birth-to-five care providers, and Native Americans will be developed by January 1, 2004. f. Plans which target outreach activities toward Hispanics, birth-to-five care providers, and Native Americans will be implemented each year beginning with FY 2005. g. Plans which target outreach activities toward specific populations (other than adolescents, faith-based organizations, Hispanics, birth-to-five care providers, and Native Americans) will be developed and implemented as data or other information indicate. h. Language and culture will not be barriers to enrollment or renewal as evidenced by the availability of telephone assistance in the customers’ preferred languages, brochures and forms in both English and Spanish, and the availability of Spanish speaking, culturally competent customer service staff. i. There will be an incremental reduction from year to year, in the percentage of children canceling ALL Kids coverage due to nonparticipation in the renewal process.

3. Performance Goal for Objective 3: There will be maintenance of effort or an increase, on the part of CHIP, to decrease the number of uninsured low-income (Medicaid eligible) children as evidenced by at least the following: i. Continued use of a joint application form. ii. Continued use of a joint renewal form iii. Continued referral, without any barriers, of applications and renewals between ALL Kids and SOBRA Medicaid iv. Continued outreach efforts by CHIP staff for network building with community groups, professionals (individually and in groups), child care providers, schools, etc.

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v. Continued evaluation and monitoring of the application transfer/referral process between ALL Kids and Medicaid. vi. Continued computer enhancements to improve the communication with other agencies and current and potential ALL Kids enrollees.

4. Performance Goals for Objective 4: a. A higher percentage of families report that their ALL Kids enrolled child(ren) have a usual source of care since enrollment in ALL Kids than before enrollment in ALL Kids. b. A lower percentage of families report that their ALL Kids enrolled child(ren) have used a hospital emergency room since enrollment in ALL Kids than before enrollment in ALL Kids.

5. Performance Goals for Objective 5 a. A higher percentage of families report that their ALL Kids enrolled child(ren) have had a well child check-up in the past year since enrollment in ALL Kids than before enrollment in ALL Kids. b. A higher percentage of families report that their ALL Kids enrolled child(ren) have had a dental visit in the past year since enrollment in ALL Kids than before enrollment in ALL Kids. c. A higher percentage of families report that their ALL Kids enrolled child(ren) have had a vision screening in the past year since enrollment in ALL Kids than before enrollment in ALL Kids.

6. Performance Goal for Objective 6: a. Contracts with state agencies which serve children with special health care needs will be maintained for the purpose of providing specialty services beyond the basic ALL Kids coverage package for these children. b. Exploration of the feasibility of establishing contracts with other state agencies that serve children with special health care needs. c. Continued monitoring of access to specialty care for children with special health care needs.

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.

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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 457.710(d)) Assurance of an Objective Means for Measuring Performance To ensure an objective evaluation which can be independently verified, the evaluation will be based upon data bases which contain quantifiable information. These databases will, to the extent possible, contain numeric data. The ADPH will develop and/or direct the development of needed databases which do not currently exist. Since evaluation of some performance measures does not lend itself to numeric summation, measurement of these aspects of the plan will be based on review of a completed work plan which requires conclusive documentation. All data and documentation will be auditable. At periodic intervals, a formal comparison of program performance to the goals and measures set forth in this document or its subsequent amendments will be conducted. The CHIP staff directly responsible for the implementation of the program will conduct information comparisons of performance to these goals and measures on an ongoing basis. In this way, the program will be continuously monitored and activities may be adjusted so that the program may achieve its objectives.

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Measure of Performance: MEASURE ROUGH DEFINITION OF MEASURE

Reducing the Number of Uninsured Number of Uninsured CPS and/or NSAF and state data survey Tracking System Documentation that a tracking system exists and is used for 100% of the applications that are referred among ALL Kids, Medicaid, and Alabama Child Caring Foundation Related to SCHIP Enrollment Percentage of families not renewing due Renewal database – comparison of number of non- to owing past premiums renewals who owed premiums to the number who were due to renew. Percentage of families reporting a New enrollee survey database – comparison of percentage reduction in financial barriers to of reports indicating a reduction in financial barriers to accessing health care obtaining health care post-ALL Kids to pre-ALL Kids Development of plans to target outreach Documentation of development of these plans on file to adolescents, faith-based organizations Implementation of plans to target Documentation of implementation of these plans on file outreach to adolescents, faith-based organizations Development of plans to target outreach Documentation of development of these plans on file to Hispanics, Native Americans, and birth-to-five providers

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Implementation of plans to target Documentation of implementation of these plans on file outreach to Hispanics Native Americans, and birth-to-five providers Development and implementation of Documentation of development and implementation of plans to target outreach to other these plans on file groups Elimination of language and culture Spanish and English brochures and applications forms on barriers file

Employment of bi-lingual customer service staff

ALL Kids Customer service telephone operators are aware of and know how to use a telephone translating service. Reduction in percentage of children Enrollment Data Management system – Comparison of canceling ALL Kids due to number of enrollees who did not participate in the renewal nonparticipation in the renewal process to those due to renew. process Related to increasing Medicaid Enrollment Maintenance of effort with regard to: Use of a joint application form A joint SOBRA Medicaid and ALL Kids application form is in use Use of a joint renewal form A joint SOBRA Medicaid and ALL Kids renewal form is in use

Seamless referral between ALL Seamless referral policy in place Kids and SOBRA Medicaid SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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Continued outreach effort Outreach/Marketing files reflect outreach conducted by central office staff, regional staff, and federal program office. Evaluation of application transfer Evaluation on files of meeting minutes and referral process Continued computer Computer enhancements will be in place. enhancements Related to increasing access to care Reported usual source of care New Enrollees Survey Reported ER use New Enrollees Survey Related to use of preventive care Reported use of well-child check-up New Enrollees Survey Reported dental visit New Enrollees Survey Reported vision screening New Enrollees Survey Other

Specialty service availability Contract(s) on file

Exploration of feasibility for Documentation on file (central office files and/or establishing contracts with other regional coordinator files) CSHCN state agencies

Monitoring access to care for CSHCN New Enrollees Survey

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Check the applicable suggested performance measurements listed below that the State plans to use: (Section 2107(a)(4)) 9.3.1. The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2. The reduction in the percentage of uninsured children. 9.3.3. The increase in the percentage of children with a usual source of care. 9.3.4. The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5. HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6. Other child appropriate measurement set. List or describe the set used.

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

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) SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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Alabama assures it will comply with the annual assessment and evaluation required under Section 10. On an annual basis, the Alabama will review its operations, progress made in reducing the number of uncovered low-income children, progress made in meeting the goals and objectives stated in 9.1 and 9.2 of this document, and its compliance with applicable Federal laws and regulations. Section 9.3 states how Alabama will measure the goals and objectives in sections 9.1 and 9.2. Examples of data sources are: Census data, private foundation garnered data, data gathered via special surveys, utilization data from claims reports, enrollee family feedback from surveys, etc. The assessment will occur during the three months after the end of the fiscal year and a report of this assessment will be submitted to the Secretary by January 1 following the end of the fiscal 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) Alabama assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit.

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)) Alabama assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed

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

9.8.1. Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2. Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3. Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4. Section 1132 (relating to periods within which claims must be filed)

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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))

Efforts were made to make the process of developing the design and implementation of the Children’s Health Insurance Program inclusive. News coverage about the advocacy of the Children’s Health Insurance Program was provided regularly starting at the time that the issue came before the Alabama Legislature.

Formalized CHIP development groups were the CHIP Commission and the CHIP Task Force Work Groups. The CHIP Commission met three times, October 7, November 12 and December 17, 1998. The CHIP Task Force Work Groups met twelve times beginning August 6, 1998, and split into subcommittees to develop proposals in the following areas: (1) benefits, (2) eligibility, outreach and enrollment, and (3) funding. These subcommittee meetings were open to interested individuals and groups. At least three news conferences were held by the State Health Officer and/or the Medicaid Commissioner.

Public awareness was promoted through means such as television programs. Interested organizations such as Alabama ARISE, the Alabama Developmental Disabilities Planning Council, and Voices for Alabama’s Children were provided information for their membership about CHIP. Media coverage was provided and CHIP information has been made available on the Internet at: http://www.adph.org/allkids (formerly: http://www.alapubhealth.org) since October 2, 1998. During the first six and one-half month period of October 4 through April 21, 1998, 1,247 hits were made on this site specifically requesting CHIP information. This website includes a description of the program, a calendar of scheduled events, and an opportunity for interested persons to express their opinions about the program’s development. Order forms are available at every presentation. These forms enable participants to fax orders to the ALL Kids office and receive printed materials at no charge. The largest number of requests for information (312) came during the month of January. Newspaper editorials have praised the value of this program for our State’s children.

The CHIP Task Force Work Groups were comprised of employees of the Alabama Medicaid Agency, Public Health Department employees, and other interested parties including representatives of the Alabama Primary Care Association, Alabama ARISE, the Alabama Developmental Disabilities Planning Council, Voices for Alabama’s Children, the Alabama Child Caring Foundation, Alabama Dental Association, Alabama Hospital Association, Alabama Psychological Association, American Academy of Pediatrics-Alabama Chapter, Blue Cross Blue Shield, Children First, Children’s Health System, Children’s Hospital of Alabama, Family Voices, Health Maintenance Organization Association, Legislative Fiscal Office, Legislative Reference SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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Service, Medical Association of the State of Alabama, University of Alabama at Birmingham, University of South Alabama, University of South Alabama Children’s and Women’s Hospital, United Health Care, as well as other State agencies including the Department of Education, the Department of Human Resources, the Department of Mental Health/Mental Retardation, State Employees’ Insurance Board, State Insurance Department, and the Department of Rehabilitation Services. These entities are now referred to as stakeholders and they continue to be involved as program changes are developed.

The Alabama program will continue to inform the general public about CHIP through the news media, to announce planning meetings, and to invite additional groups with an interest in being involved or informed as they become identified. There was extensive public involvement in the preparation of a comprehensive 133-page report which was released to the Alabama Legislature on January 12, 1998. In relation to the Governor’s Task Force on Children’s Health Insurance, periodic reports on the progress of recommendations contained the report are made. 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)) A meeting was held with representatives of the 2,176 member Poarch Band of Creek Indians, the only federally recognized Native American group in Alabama. Six other tribes are recognized by the State. The CHIP Program was explained and discussion centered on ways to coordinate CHIP and Indian Health Service-funded care, the role of traditional Native American healing, outreach methods for children and some demographics of the Poarch Band. Several presentations have been made to the Alabama Commission on Indian Affairs and CHIP staff meet and coordinate regularly with staff of the Commission. Other forms of outreach have included numerous presentations to the tribes, presence at Native American festivals throughout the state and the employment of a Native American consultant whose specific task was to develop a regionally- based outreach plan to the Native American population in Alabama.

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 CFR457.65(b) through (d).

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Alabama has no state law applicable to public notice of either cost sharing changes or waiting list implementations in CHIP.

Public Notice of Cost Sharing Changes: Specific public notice was given via a meeting of CHIP stakeholders in August 2003 and letters to enrollees’ families informing them of the changes in cost sharing. This meeting and the mailings followed much publicity in the state regarding the state’s financial situation and the possible impact on CHIP if a statewide referendum to raise taxes on (September 9, 2003) did not pass.

Public Notice of the Waiting List: ALL Kids initiated a waiting list beginning with all new enrollees who would have had an effective date October 1, 2003. Once the decision had been made to establish a waiting list, a press statement was released and letters were sent to stakeholders and other interested parties informing them of the institution of a waiting list and stressing the importance of returning renewal forms on time. Additionally, a letter to this effect was sent to every enrollee family along with a new insurance card(s). All of these notices were issued during the month of September 2003 prior to the impact of the waiting list.

On August 23, 2004, ALL Kids reopened enrollment and discontinued use of the waiting list.

If the State determines that it is again necessary to implement a waiting list, it will provide prior, appropriate public notice.

There are no public notice state laws regarding enrollment caps and waiting lists in SCHIP. 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.

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 SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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limited to expenditures for targeted low income children, the optional coverage of the unborn, lawfully residingeligibles, 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

CHIP Budget STATE: AL FFY Budget Federal Fiscal Year 2019 State’s enhanced FMAP rate 100%

Benefit Costs Insurance payments 229,609,117 Managed care per member/per month rate 220 Fee for Service Total Benefit Costs 229,609,117 (Offsetting beneficiary cost sharing payments) -6,500,000

Cost of Proposed SPA Changes – Benefit 3,300,000 Net Benefit Costs 226,409,117

Administration Costs Personnel 5348138 General administration 2485677 Contractors/Brokers SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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STATE: AL FFY Budget Claims Processing Outreach/marketing costs 174000 Health Services Initiatives $753,625 Other 1,283,553 Total Administration Costs 10,044,993 10% Administrative Cap 25,156,569

Cost of Proposed SPA Changes 4,053,625

Federal Share 236,454,110 State Share 0 Total Costs of Approved CHIP Plan 236,454,110

NOTE: Include the costs associated with the current SPA. Costs associated with the two changes contained within SPAs AL-19- 0017-RIM And AL-19-0018-RIM total $4,053,625. The entire cost would be paid for through Federal funds in FY 2019. For the expansion of benefits to provide coverage from conception to birth in select counties (AL-19-0018-RIM), costs are estimated to be $3,300,000 and are reflected within the line item “benefits.” The other budget item addressed in these SPAs includes costs for implementing a health service initiative (HSI) (AL-19-0017-RIM). HSI costs are projected to be $753,625 for the remaining of FY2019.

The Source of State Share Funds: No state funds will be used.

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

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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.

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 collection program) SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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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. Alabama’s appeals process meets the requirements of the Program Specific Review as outlined in CFR.457.1120 – 457.1180. The ALL Kids appeals and grievance process can be found in Attachment A. The individuals involved in the Information review (first level) are not involved in the Administrative Review (second level) thus impartiality in the appeals process is provided. The individuals who conduct the Administrative Review are not involved in the Information Review process not in the original determination process. The review process for children enrolled in a CHIP Medicaid expansion is the same as the review process for children enrolled in other Medicaid full service children’s programs 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.

The State assures that the State laws or regulations are consistent with the intent of 42 CFR 457,1130(b). This grievance process for health service matters is provided by the insurance vendor and is in compliance with state laws, the Employee Retirement Income Security Act of 1974 (ERISA), and all other applicable regulations of the Department of Labor Procedures. A copy of the Blue Cross Blue Shield of Alabama appeals process can be found in the ALL Kids Summary Plan Description (SPD) which is available upon request. The grievance process for children enrolled in a CHIP Medicaid expansion is the same as the review process for children enrolled in other Medicaid full service children’s programs.

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.

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ATTACHMENT A

GRIEVANCE POLICY

General Information

Applicants and enrollees of the ALL Kids Children’s Health Insurance Program (CHIP) have a right to discuss and question how eligibility for enrollment was determined. In particular they have the right to request review of program decisions concerning:

• Denial of eligibility • Failure to make a timely determination of eligibility • Suspension or termination of enrollment, including disenrollment for failure to pay premiums.

The ALL Kids Review Process has three levels of review--Information Review, Administrative Review and Formal Review. Requests for an Administrative Review and Formal Appeal must be submitted in writing. All correspondence with the applicant /enrollee concerning Administrative Review or Formal Review will be in writing.

ALL Kids Plus Services Requests for review of decisions made regarding eligibility for the ALL Kids Plus services must first be made to the ALL Kids Plus participating agency’s appropriate appeals process. This is necessary since eligibility for ALL Kids Plus is dependent on the participating agency’s eligibility criteria for services. Once the appeals process through the ALL Kids Plus participating agency has been exhausted, an appeal request may be made to the Children’s Health Insurance Program as described in ADPH ALL Kids Review Process.

Information Review In many cases problems can be handled informally through the Information Review Process without the need for a Administrative or Formal Review. CHIP staff is committed to using the Information Review process to provide a speedy and fair resolution when possible and appropriate.

Parents/designated representatives can initiate an Information Review via contact (telephone, e-mail or letter) with the Enrollment Unit supervisory staff, CHIP administrative staff, the CHIP social work consultant, CHIP regional staff, or interested agencies. Once the problem has been received, the appropriate staff will review the situation and initiate immediate action to resolve the problem and SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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communicate the decision or resolution. If additional information is needed, the enrollee/applicant will be given the opportunity to provide clarification or submit additional information. Decisions made in the Information Review are usually provided within two working days. Notification to the applicant/enrollee will be communicated in the manner in which the request was made. Summation of the inquiry, review and resolution will be maintained on file and noted with the appropriate applicant/enrollee information.

If the problem remains unresolved in the eyes of the applicant/enrollee, they will be provided detailed information regarding their right to a Administrative Review, right to continued enrollment during the review process and provided copies of all forms and the procedures necessary to move forward through the review process. Appropriate notation will be kept in the applicant’s/enrollee’s electronic file noting the initial complaint, any information gathered during the Information Review, the decision reached through Information Review, the date of such decision and the applicant/enrollees intent to go forward with the Administrative Review Process.

Administrative Review In order to be considered, an Administrative Review Request Form must be received within ten (10) days of the final decision from the Information Review. The CHIP social work consultant will assist in gathering information that may clarify the request. All information on file from the Information Review and any information gathered by the CHIP Social Work consultant will be circulated to a three person Administrative Review Committee whose members were not involved in the Information Review process nor in the original determination process.

The applicant/enrollee will be notified in advance of the date and time that the Administrative Review Committee will be hearing information regarding their situation. They have the right to speak in person or have a representative of their choosing present during the review. They may also submit additional information and review program records and guidelines pertaining to the matter under grievance.

The Committee’s decision and the Program Director’s review of the decision must be completed within thirty-days (30) of receiving the Administrative Review Request Form. Applicant/enrollees will be notified in writing of the Administrative Review Committee’s decision within three working days of the decision. Additionally this notification will include the applicant/enrollee’s rights to continued review and the policy regarding a request for Formal Review by the State Health Officer.

If the grievance remains unresolved in the applicant/enrollee’s eyes, the applicant/enrollee may file a request for a Formal Review by the State Health Officer.

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Formal Review In order to be considered by the State Health Officer, a Request for Formal Review must be submitted to the CHIP office within ten (10) days of the final decision of the Administrative Review Committee. This request must be submitted on the Formal Review Request Form.

The applicant/enrollee will be notified in advance of the date and time that the State Health Officer will be hearing information regarding their case. Applicants/enrollees may appear in person or have a representative of their choosing to present information the State Health Officer. They may also submit additional information and review program records and guidelines pertaining to the matter under grievance.

Generally a decision will be issued within thirty-days (30) following receipt of the Request for Formal Review. Applicants/enrollees will be notified of the decision of the State Health Officer within three (3) working days of the decision.

The decision made by the State Health Officer is the final step in the administrative proceedings and will exhaust all administrative remedies.

Expedited Review If the enrollment or eligibility matter under review would worsen health conditions of the applicant/enrollee or jeopardize lives, an expedited CHIP review may be provided. An Expedited Review will be made within seventy-two (72) hours by quickly obtaining and reviewing information so as not to cause unnecessary harm to the applicant/enrollee.

Right for Continued Benefits During Appeals Process When the eligibility decision under review concerns renewal or re-determination of coverage, and the enrollee files a Request for Administrative Review, CHIP staff will ensure that coverage for that enrollee is continued until the review process is completed. The enrollee will be notified in writing of this continuation of coverage and their responsibility regarding any health services costs incurred if the resulting review decision supports termination of coverage. The enrollee will be issued a temporary health plan identification card with a coverage end date equal to the maximum length of time allowed for both the Administrative and Formal Review processes.

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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)

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CMS Regional Offices CMSRegion Associate Regional States Regional Office Address al Offices Administrator 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 4th 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- Iowa Missouri James G. Scott Richard Bulling Federal Bldg. Kansas City Kansas Nebraska james.scott1@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

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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GLOSSARY Adapted directly fromSec. 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 SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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language disorders. 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) SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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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 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.

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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Implements a health services initiative (HSI) to provide prenatal monitoring, case management and care coordination services to pregnant women and their infants in Montgomery, Macon, and Russell counties. AL-19-AL-19-0018-RIM expands coverage for unborn children residing in Montgomery, Macon, and Russell counties.

Approval Package

_____________________________________________________________________________

Table of Contents

State/Territory Name: Alabama

State Plan Amendment (SPA) #: AL-21-0022

This file contains the following documents in the order listed:

1) Approval Letter 2) State Plan Pages

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

Children and Adults Health Programs Group

July 2, 2021

Scott Harris, MD, MPH State Health Officer Alabama Department of Public Health Post Office Box 303017 Montgomery, AL 36130-3017

Dear Dr. Harris:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) AL- 21-0022, submitted on May 14, 2021 has been approved. This amendment implements a health services initiative (HSI) to provide comprehensive health coverage during the 60-day postpartum period to individuals whose pregnancies were covered under the Reducing Infant Mortality Conception to Birth program known as ALL Babies. This amendment has an effective date of July 1, 2021.

Section 2105(a)(l)(D)(ii) of the Social Security Act (the Act) and 42 CFR §457.10 authorize use of title XXI administrative funding for expenditures for HSIs under the plan for improving the health of children, including targeted low-income children and other low-income children. Consistent with section 2105(c)(6)(B) of the Act and 42 CFR §457.626, title XXI funds used to support an HSI cannot supplant Medicaid or other sources of federal funding.

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

Your title XXI project officer is Jack Mirabella. They are available to answer questions concerning this amendment and other CHIP-related issues. Their contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, MD 21244-1850 Telephone: (410) 786-2424 E-mail: jack.mirabella@cms.hhs.gov

TEMPLATE FOR CHILD HEALTH PACWLAN 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: Alabama (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)) Scott Harris, State Health Officer, Alabama Department of Public Health (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: Teela Sanders Position/Title: CHIP Director Name: Shaundra Morris Position/Title: Director, ADPH Financial Services

*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.

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Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 105-33amended 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 457as 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. ASPA 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

Effective Date: March 1, 2020 2 Approval Date:

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)); (42CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of

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health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary- approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The 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

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benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

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

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)

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

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

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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))

* Until October 1, 2002, Alabama’s CHIP was a combination program. With the mandated gradual increase of Medicaid coverage at higher income levels for children born after September 30, 1983, the Medicaid expansion portion of CHIP was subsumed, on October 1, 2002, by the Alabama Medicaid SOBRA Program for Pregnant Women and Children.

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))

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Alabama has not and will not claim expenditures for child health assistance prior to the time that the State has legislative authority to operate the State 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. (42CFR 457.130)

Assurances are on file with DHHS. The Alabama Department of Public Health continues to assure that compliance 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 Plan Effective Date: February 1, 1998 Amendment 1 – Establishment of ALL Kids Effective Date: February 1, 1998 Implementation Date: October 1, 1998 Amendment 2 – Establishment of ALL Kids PLUS Effective/Implementation Date: October 1, 1999 Amendment 3 – Disregards Effective/Implementation Date: June 1, 2001 Amendment 4 - Compliance Effective/Implementation Date: August 24, 2001 Amendment 5 – Waiting List, Cost Sharing, Benefit Changes Effective/Implementation Date: October 1, 2003 Amendment 6 – Discontinuance of the Waiting List and other Clean-Up changes Effective/Implementation Date: November 23, 2004

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Amendment 7 – Raise the upper income eligibility limit to 300% of FPL and other minor changes Effective/Implementation Date: October 1, 2009 Amendment 8 – Include a private foundation grant as an additional source of state funding Effective/Implementation Date: October 27, 2009 Amendment 9 – Establishment of a Prospective Payment System for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) Effective/Implementation Date: October 1, 2009; Addendum on Dental Benefits Under Title XXI: Effective/Implementation Date: October 1, 1998 Amendment 10 – Eligibility for children of employees of a public agency (state employees and public education employees) Effective/Implementation Date: January 1, 2011 Amendment 11 – Provisions for Implementing Temporary Adjustments to Enrollment Determination and/or Redetermination Policies and Cost Sharing Requirements for Applicants/Renewals living in and/or working in FEMA or Governor declared disaster areas at the time of a disaster event. In the event of a disaster, the State will notify CMS of the intent to provide temporary adjustments to its enrollment and/or redetermination policies, the effective dates of such adjustments and the counties/areas impacted by the disaster. Effective/Implementation Date: April 15, 2011 Amendment 12 – Increase premiums, increase co-pays and revise the methodology for determining annual aggregate cost-sharing Effective/Implementation Date: May 1, 2012 Amendment 13 – Establishment of copayments for therapy services (physical, occupational, and speech), vision services and chiropractic services; and cleanup changes Effective/Implementation Date: August 1, 2013 Amendment 14 – Alignment of ALL Kids fee groups with provisions of the Affordable Care Act (ACA) and other editorial changes to comply with previously approved ACA SPAs. Effective/Implementation Date: January 1, 2014 Amendment 15 - AL-16-0015-MEXP – CHIP Medicaid expansion to cover Medicaid enrollees ages 14 years to 19 years with incomes above 18% FPL through 141% FPL. Effective Date: October 1, 2015 Implementation Date: January 1, 2016 Amendment 16 – AL-18-0016-PAR - Attestation and documentation of Mental Health Parity and Addiction Equity.

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Submission Date: July 10, 2018 Proposed Effective Date: October 1, 2017* Implementation Date: October 1, 2017* *Note: Benefits were adjusted in October 2010 to be compliant with mental health parity; this amendment did not require any benefit changes Amendment 17 – AL-19-0017-RIM - Reducing Infant Mortality (RIM) Health Service Initiative Submission Date: July 17, 2019 Proposed Effective Date: July 1, 2019 Implementation Date: July 1, 2019 Amendment 18 – AL-19-0018-RIM CS9 Eligibility – Coverage From Conception to Birth Submission Date: July 17, 2019 Proposed Effective Date: July 1, 2019 Implementation Date: July 1, 2019 Amendment 19 – AL-20-0019-CEN CS15 MAGI-Based Income Methodologies – Temporary Income Submission Date: February 26, 2020 Proposed Effective Date: March 1, 2020 Implementation Date March 1, 2020 Amendment 20 – AL-20-0020-COVI Allowing for Temporary Waiving of cost sharing requirements for enrollees who reside and/or work in a State or Federally declared disaster area. Submission Date: July 29, 2020 Implementation Date: March 1, 2020 Effective Date: March 1, 2020 Amendment 21 - AL-20-0021-BH Documentation of AL CHIP compliance with the SUPPORT Act. Submission Date: July 29, 2020 Implementation Date: October 24, 2018

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Amendment 22 – AL-21-0022-PP Postpartum coverage Health Services Initiative for ALL Babies Submission Date: May 13, 2021 Proposed Effective Date: July 1, 2021 Implementation Date:

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Transmittal Number SPA PDF Description Superseded Group # Plan Section(s) AL-14-0016 MAGI CS7 Eligibility – Targeted Low Supersedes the (Original: AL-14-0016 Eligibility Income Children current Effective/Implementatio & sections n Date: January 1, 2014) Methods Geographic Children With Access to Area 4.1.1; Age CS10 Public Employee Coverage 4.1.2; and AL-19-2020-CEN Income 4.1.3 (affects only CS15) Section 4.4.1: Effective/Implementati Supersedes on Date: March 1, 2020 only the MAGI-Based Income information on CS15 Methodologies dependents of public employees in this section; supporting documentation should be incorporated as an appendix to the current state plan

Incorporate within a separate subsection under section 4.3

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AL-19-0018-RIM CS9 Coverage from Effective Date: July 1, Conception to Birth 2019 Implementation Date: July 1, 2019)

(Original: AL-14-0014 XXI CS3 Eligibility for Medicaid Supersedes the Effective/Implementatio Medicaid Expansion Program current n Date: January 1, 2014) Expansio Medicaid n expansion AL-16-0015-MEXP CHIP Medicaid expansion section 4.0 to cover Medicaid Effective/Implementati enrollees ages 14 years to on Date: October 1, 19 years with incomes 2015 above 18% FPL through 141% FPL AL-14-0015 Establish CS14 Children Ineligible for Incorporate 2101(f) Medicaid as a Result of the within a Effective/Implementati Group Elimination of Income separate on Date: January 1, Disregards subsection 2014 under section 4.1 AL-14-0018 Eligibility CS24 Single, Streamlined Supersedes the Process Application current Effective/Implementati Screen and Enroll Process sections 4.3 on Date: January 1, Renewals and 4.4 2014 AL-14-0017 Non- CS17 Non-Financial Eligibility – Supersedes the Financial Residency current section Effective/Implementati Eligibility 4.1.5 on Date: January 1, CS18 Non-Financial – Citizenship 2014 Supersedes the CS19 Non-Financial – Social current Security Number sections 4.1.0; 4.1.1-LR; 4.1.1- CS20 Substitution of Coverage LR

CS21 Non-Payment of Premiums Supersedes the

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current section CS27 Continuous Eligibility 4.1.9.1

Supersedes the current section 4.4.4

Supersedes the current section 8.7

Supersedes the current section 4.1.8

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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. In accordance with approved policies, on April 12, 2021, a certified letter explaining the changes proposed AL-21-0022 was mailed to the Tribal Chair of the one federally recognized Native American tribe in Alabama, the Poarch Band of Creek Indians. The letter included the purpose for the proposed changes and a description of the changes. In the letter, the Tribal Chairman was also reminded that she had the opportunity to respond to the proposed changes within 30 days and was given contact information for any such response. The certified letter was signed by the CHIP Director. TN No: Approval Date Effective Date: May 12, 2021

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))

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Prior to CHIP, the only two programs offering health insurance to low-income children were Medicaid and the Alabama Child Caring Foundation (ACCF). Medicaid served children at the minimum income levels required by federal law. This meant that Medicaid coverage was available to children at three different levels of income and age: - Those under the age of six (6) years with incomes up to 133% FPL; - Those children six (6) through 14 years of age who were born after September 30, 1983 with incomes up to 100%FPL; and, - Those remaining children through the age of 18 years (middle and older teens) with incomes at the TANF assistance level (below approximately 13% FPL). The ACCF served children (birth through 18 years) with incomes from the Medicaid levels up to 200% FPL.

From February 2, 1998 through September 30, 2002, Phase I of CHIP, a Medicaid expansion was in existence. On October 1, 2002, Phase I of Alabama’s CHIP was subsumed by the Alabama SOBRA Medicaid Program. Beginning October 1, 2015, however, children in this category (ages 14 to 19 with incomes between 13% FPL and 141% FPL) will again be enrolled in a CHIP Medicaid expansion.

Originally, CHIP used a baseline number of uninsured children derived from the Current Population Survey (CPS). This baseline including the following chart was derived from a study by Winterbottom et.al. based on a three year merged Current Population Survey, or CPS, (1990-92), which showed over 200,000 children, in Alabama, under 18 years to be uninsured.

Employer Medicaid Other Uninsured Coverage Percent 59.3 17.2 5.1 18.4 Number 652,300 189,200 110,000 202,400

However, due to concerns about the CPS regarding potential problems with subjects’ abilities to recall information, Alabama changed its baseline estimate to reflect data from the 1997 round of the Urban Institute’s National Survey of America’s Families (NSAF). The NSAF indicated that there were 173,012 uninsured children in Alabama. Of these, 91,209 were < 100% Federal Poverty Level (FPL), 49,579 were above 100 up to 200% FPL and 32,223 were >200% FPL.

In its first 4 years of implementation (October 1, 1998 – September 30, 2002), Phase II, ALL Kids, enrolled over 80,000 children. It is estimated that 52,000 children have current enrollment in ALL Kids at the end of FY 2002.

ALL Kids PLUS, added as a third amendment to the CHIP State Plan (October, 1999), serves as a mechanism by which children with special health care needs/conditions (CSHCN/C), who

Effective Date: March 1, 2020 16 Approval Date:

are enrolled in ALL Kids, may receive health and health related services which are beyond the scope of the basic ALL Kids package. ALL Kids PLUS was designed so that it serves as a funding source for CHIP state match and as a funding mechanism for state agencies who serve CSHCN/C with state funds. State agencies participating in ALL Kids PLUS supply the state match, provide the service, and receive full reimbursement. It was originally estimated that approximately 9% of these enrollees would also receive at least one service under ALL Kids PLUS. However because the basic benefit package is so comprehensive, a much lower percentage of children are receiving PLUS services. It is expected that this percentage will increase as more state agencies contract with CHIP to become ALL Kids PLUS providers. With the advent of ALL Kids, the ACCF has changed its income eligibility criteria to serve children who are not eligible for Medicaid or ALL Kids and who have incomes up to 235% FPL. Because, the ACCF has no enrollment restriction regarding immigrants, this program has seen a dramatic increase in its Hispanic enrollment.

Guidance: Section 2.2allows 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 at42 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) HSI I: ALL Babies Case Management: As permitted under section 2105(a)(1)(D)(ii) of the Social Security Act and federal regulations at 42 CFR 457.10, the State of Alabama is implementing a health services initiative (HSI) that will use CHIP funds, within the federal administrative expenditures cap allowed for states, to support the Reducing Infant Mortality (RIM) Health Services Initiative. The aim of this initiative is to reduce the infant mortality rate in selected counties within Alabama through the provision of a variety of evidence-based case management services for pregnant women and children. These case management services will target health, social, and behavioral health related high-risk factors which have been shown to impact pregnancy outcomes and infant health. Case Management services will connect patients, with high-risk factors, to appropriate services and case managers will follow-up to ensure that risk factors are being addressed satisfactorily. It is anticipated that the case manager will make a total of 6 face to face visits. Three visits would occur during the prenatal care, and three visits would be provided post delivery.

The care coordination services provided postpartum including services to the infant include:

i. Make home visit within one month following delivery to complete the following: 1. Encourage patient to keep postpartum appointment including providing appointment reminders to help ensure completion of the postpartum appointment.

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2. Encourage patient to choose a reliable birth control method. If the patient has chosen sterilization as her method, follow-up with the patient to ensure the procedure is completed. 3. Ensure patient is established with a PMP for the infant. 4. Ensure infant has enrolled in WIC, if eligible. 5. Educate the patient on the importance of immunizations for the infant. ii. Assist in scheduling appointments with infant’s PMP up to the first year to ensure that well baby checkups are made and immunizations are up to date. Follow up after the appointments to verify that appointments were kept. Well Baby checkups are scheduled at: a. 1 month b. 2 months c. 4 months d. 6 months e. 9 months f. 12 months iii. Promote the child’s overall physical, cognitive, and emotional development through educating parents/caregivers about developmental milestones according to the child’s age and developmental abilities. iv. Complete an ASQ-3 (Ages and Stages Questionnaire, Third Edition, a developmental screening tool) as appropriate at face to face appointments. v. Educate the parents about the importance of reading to the infant to promote cognitive development. vi. Make referrals for the child, as appropriate, such as Early Intervention, Children’s Rehabilitation Services, etc. vii. Prior to the child’s first birthday, ensure he/she is established with a dentist. viii. Screen the mother for post-partum depression at each face to face visit and make referrals and follow up (as needed)

With the exception of providing necessary prenatal monitoring by a nurse in the home or health department setting, no HSI funds will be spent on direct care.

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The high-risk factors that HSI will address include the following: ACEs Score of >4 Depression1 Diabetes Mellitus Current multiple births Substance Abuse2 Maternal age3 Hypertension Interpersonal safety Transportation needs Housing Instability Food Insecurity Utility needs Abuse4 Enrollment in CHIP unborn coverage Prior poor pregnancy outcome5

To be eligible for the HSI, pregnant women and/or their infants in selected counties must have at least one of the high-risk factors cited above and have an income no greater than the upper CHIP limit (currently 312% FPL). HSI services will be offered whether or not the patient has health insurance coverage and regardless of the type of insurance. Case management services for individuals enrolled in Medicaid will be time-limited until the implementation of the case management services provided in the Alabama Coordinated Health Network (ACHN) scheduled to begin October 1, 2019. Individuals with other insurance that are provided case management services will not be provided case management services using HSI funds.

Patients will be enrolled in the HSI initiative during pregnancy, during the post-partum period, or by referral. Once enrolled, HSI services will continue, as appropriate, for one-year post delivery with the exceptions noted in the paragraph above.

The HSI will be coordinated by the Alabama Department of Public Health and delivered through designated county health departments. Depending upon the needs of those participating in the initiative, services may be provided by public health nurses, public health social workers, community health workers, etc.

The proposed counties for initial implementation of the HSI include Montgomery, Macon and Russell counties. Services supported through this HSI will not supplant other federal, state or local funds allocated for similar services.

Outreach activities for the RIM HSI include providing education and information to pertinent providers, hospitals and programs serving the target population residing in the counties in which the expansion is implemented.

1 Depression noted at anytime during the pregnancy or postpartum period (90 days postpartum) 2 History of use or current substance use 3 <21 or >35 4 Emotional, physical, or sexual 5 Fetal Death – Stillbirth after 20 weeks; Infant death -first year of life; Preterm birth - <37 weeks gestation; Low Birthweight - <2500 grams; Very Low Birthweight - <1500 grams; Other serious chronic conditions (ex: heart disease, renal disease, chronic medical illnesses, etc.); and, Maternal Death (death of a woman while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes).

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In monitoring/evaluating the progress and success of this program, the total number of women and children served will be captured and reported to ALL Kids on an agreed upon schedule but no less than a quarterly basis. Tracking and reporting of visits and birth outcomes (birth weight, mortality within the first year of life and maternal health indices) will also be included in reports to ALL Kids.

The cost of the HSI is budgeted to be $753,625 for FY 2019 (July –Sept).

Case Management Costs: Initially, within the proposed three county area, approximately 500 women/families could be served in FY 2019. The number of case management hours per person/family is estimated to be 10 hours/quarter at an average cost of $135/hour. This hourly rate would account for salary cost of those providing/coordinating services. Additionally, it is estimated that staff will travel 25 miles per home visit and there will be two home visits/patient/quarter at the state mileage reimbursement rate of $0.545/mile.

Annual 1st Quarter Case Management: Enrollees X case management hours $2,700,000 $675,000 X $135.00/hour Travel: # enrollees X miles/round trip X 2 trips/quarter X mileage $ 54,500 $ 13,625 reimbursement rate

Start Up/Outreach Costs: As the HSI is being developed, costs are being allocated for personnel support to include up to two FTEs (one full-time project manager and other ancillary support staff as needed). Additionally, costs are included for the development of materials to promote and educate health care providers and community organizations throughout the implementation counties about the initiative and to garner support and participation of agencies/providers. Education and awareness materials to outreach to women will also be prepared. Expenses to conduct (as well as attend) meetings, conferences and/or trainings to share information about the program and generate participation are also included as part of the startup and implementation costs.

Annual 1st Quarter Personnel Costs (Salary, Fringe, Indirect costs) $200,000 $50,000 Educational/training materials $ 10,000 $10,000 (providers/organizations and participants) Costs for meetings (transportation/meeting fees) $ 5,000 $ 5,000

Grand Total: $2,969,500 $753,625 (Personnel, Materials, Meeting costs, Case Management)

HSI II: ALL Babies Postpartum Initiative: As permitted under section 2105(a)(1)(D)(ii) of the Social Security Act and federal regulations at 42 CFR 457.10, the State of Alabama is

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implementing a health services initiative (HSI) that will use CHIP funds, within the federal administrative expenditures cap allowed for states, to support the ALL Babies Postpartum Initiative. This HSI will assist in improving the health of children by ensuring their mothers have access to healthcare services during their postpartum period. The aim of this initiative is to provide full health insurance coverage during the postpartum period to enrollees who have been prenatally covered in the Reducing Infant Mortality Conception to Birth program known as ALL Babies. The length of the ALL Babies postpartum period is equivalent to Alabama Medicaid’s current definition of the length of postpartum period “From delivery through the end of the month in which the 60th day postpartum falls, counting from the date the pregnancy ends either as a full term or as a miscarriage.” ALL Babies participants will be enrolled automatically in the postpartum HSI initiative. Metrics used to measure the impact of the state’s HSI program on the health of low-income children and their mothers will be included in the state’s CHIP Annual Report.

Cost: The cost of the HSI is budgeted to be $301,250 for FY 2021. This figure is based on anticipated enrollment (500 enrollees), an average enrollment time period of 2.5 months, and a per member per month (PMPM) cost equal to the projected ALL Kids pmpm for 2021 ($241.00).

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

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

ALL Kids provides a certified letter to the federally recognized tribe in the state when considering amendments to the State Plan or other program changes requiring CMS

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approval. The tribe is given 30 days to respond. In the event of an emergency, ALL Kids will submit a faxed letter to the tribe and give 10 days for response.

Section 3. Methods of Delivery and Utilization Controls Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4. Guidance: In Section 3.1., discussion may include, but is not limited to: contracts with managed health care plans (including fully and partially capitated plans); contracts with indemnity health insurance plans; and other arrangements for health care delivery. The State should describe any variations based upon geography, as well as the State methods for establishing and defining the delivery systems.

Should the State choose to cover unborn children under the Title XXI State plan, the State must describe how services are paid. For example, some states make a global payment for all unborn children while other states pay for services on fee-for-services basis. The State’s payment mechanism and delivery mechanism should be briefly described here.

Section 2103(f)(3) of the Act, as amended by section 403 of CHIPRA, requires separate or combination CHIP programs that operate a managed care delivery system to apply several provisions of section 1932 of the Act in the same manner as these provisions apply under title XIX of the Act. Specific provisions include: section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. If the State CHIP program operates a managed care delivery system, provide an assurance that the State CHIP managed care contract(s) complies with the relevant sections of section 1932 of the Act. States must submit the managed care contract(s) to the CMS Regional Office servicing them for review and approval.

In addition, states may use up to 10 percent of actual or estimated Federal expenditures for targeted low-income children to fund other forms of child health assistance, including contracts with providers for a limited range of direct services; other health services initiatives to improve children’s health; outreach expenditures; and administrative costs (See 2105(c)(2)(A)). Describe which, if any, of these methods will be used.

Examples of the above may include, but are not limited to: direct contracting with school-based health services; direct contracting to provide enabling services; contracts with health centers receiving funds under section 330 of the Public Health Service Act; contracts with hospitals such as those that receive disproportionate share payment adjustments under section 1886(d)(5)(F) or 1923 of the Act; contracts with other

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hospitals; and contracts with public health clinics receiving Title V funding. If applicable, address how the new arrangements under Title XXI will work with existing service delivery methods, such as regional networks for chronic illness and disability; neonatal care units, or early-intervention programs for at-risk infants, in the delivery and utilization of services. (42CFR 457.490(a))

3.1. Delivery Standards 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))

Phase I - Medicaid Expansion From February 2, 1998 through September 30, 2002, Phase I of CHIP, a Medicaid expansion was in existence. On October 1, 2002, Phase I of Alabama’s CHIP was subsumed by the Alabama SOBRA Medicaid Program. As of October 1, 2015, CHIP will again expand Medicaid by covering Medicaid enrollees ages 14 years to 19 years with incomes above 13% FPL through 141% FPL.

ALL Kids: Program Operation–Administration From inception of the program in 1998 through May, 2001, ALL Kids contracted with the State Employee’s Insurance Board (SEIB) to serve as its enrollment and premium billing/receiving office. As enrollment grew, ALL Kids staff increased, and the need for data management grew, the ADPH CHIP unit and SEIB jointly decided to move the enrollment and premium billing/receiving functions to the CHIP unit. The Alabama Department of Public Health (Department) now manages all enrollment aspects of the ALL Kids program and utilizes other contractors to administer certain aspects of the ALL Kids program including, but not limited to, the following:

1. Providing all eligible persons involved in ALL Kids an individual policy or certificate that states the insurance protection provided, the method and place of filing claims, and to whom benefits are payable. The policy or certificate indicates that coverage was obtained through CHIP; 2. Maintenance of a claims database for the purpose of program management. 3. Management of evaluation surveillance procedures. 4. Consultation for actuarial services 5. Consultation for development of data systems 6. Consultation for development of specialized outreach plans

Program Operation-Benefits and Services The ALL Kids program is a self-funded, discounted fee-for-service*, PPO, delivery system. In order

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to assure delivery of the insurance product(s), the Department utilizes a private health care delivery organization(s) to provide benefits and services. Both indemnity plan(s) and or managed care plans(s) are acceptable and have been used. The selected vendor(s) is required to perform, including but not limited to, the following:

1. Furnishing coverage information and ID cards; 2. Member service responses to claims inquiries; 3. Claims certification, investigation, adjudication, and internal appeals process; 4. Processing and distribution of benefit payments to providers; 5. Appropriate and accurate fee administration; 6. Strict financial accounting and reconciliation; 7. Effective management of networks (if applicable); 8. Demonstrated capability to serve Alabama membership; 9. Effective medical, pharmacy and dental management including medical review of claims decisions; 10. Production of claims, contract, and other legal forms as required; 11. Establishment and maintenance of appropriate banking arrangements; 12. Continuous and accurate electronic transmission of all data; 13. Production of reports that capture claim and utilization experience and trends; 14. Other special services as may be requested from time to time 15. Have a network of physicians, dentists, pharmacies, and other providers capable of meeting the demands of the ALL Kids Program. 16. Facilitation of a medical home for each enrollee.

*The exception to the fee-for-service payment system is the method of reimbursement to federally qualified health centers (FQHCs) and rural health clinics (RHCs) based on a prospective payment system (PPS). This is in compliance with section 503 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA). In accordance with this provision of CHIPRA, ALL Kids has elected to adopt the Medicaid PPS Rates effective October 1, 2009. This method of payment will be implemented August 25, 2010 for all qualifying services rendered on or after October 1, 2009.

In the past, ALL Kids has used three (3) insurance venders, Blue Cross Blue Shield of Alabama (statewide), Prime Health (in 10 southwestern counties from 10/98-9/00) and United Healthcare (14 counties from 10/01-7/02) for the above services. However, due to low enrollment in Prime Health and United Healthcare (which was due to patient choice), each of those programs elected, with the mutual consent of the ALL Kids program, to discontinue serving as an ALL Kids vendor. Currently, the only ALL Kids vendor for the above services is Blue Cross Blue Shield of Alabama. This vendor provides services statewide.

CHIP makes health care coverage available to all individuals eligible for ALL Kids on a “guaranteed issue” basis with no exclusions of coverage for pre-existing conditions, and on a “guaranteed

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renewable” basis for those eligible.

ALL Kids PLUS Program Operation-Administration For this addition to the program, the Alabama Department of Public Health has partnered (and seeks to partner) with other governmental agencies (which serve special needs children) to provide the state match, provide or provide for covered ALL Kids PLUS services, to authorize case by case reimbursement for ALL Kids PLUS services, to notify ALL Kids PLUS families of their approval for services, and select one case manager per child so as to minimize duplication and gaps in services. PLUS services became available through CRS as of October 1, 2000. An ALL Kids PLUS contract was signed with the Department of Mental Health and Mental Retardation effective October 1, 2002.

Several state agencies, other provider entities, and advocates within the state have met to develop the concept and plan of operation for ALL Kids PLUS.

At the present time, the list of ALL Kids PLUS authorizing agencies is restricted to those governmental agencies supplying the state match money. If other state or appropriated matching funds become available, this restriction may be modified or eliminated. A child must be enrolled in ALL Kids to qualify for PLUS services. When a child is identified with a special condition or need that a participating agency serves, he/she is referred to that agency based on that special condition/need. This agency will, based on the availability of funds, assign a case manager to the child, authorize needed services within the agency, and make referrals to other authorizing agencies for additional services if needed. All agencies authorizing PLUS services for a child notify the child’s case manager and referral site (if different) for approval of services. Each child will only have one ALL Kids PLUS case manager. The decision as to which agency will provide the case management will be determined by the agencies involved in the child’s care and will be based on what makes the best practice sense and is in the best interest of the child.

Authorizing agencies bill the insurance vendor(s) for any authorized PLUS services that the agencies have provided directly or indirectly. The Alabama Department of Public Health reimburses the insurance vendor(s) in the same manner that reimbursement for the basic ALL Kids program is handled. At this time, the participating PLUS agencies do not utilize a central integrated data system. However, their day-to-day practice involves coordination through the case manager with other agencies to avoid duplication. Each agency submits all claims/data to the insurance vendor (BCBS) for adjudication and reimbursement. While a child may have claims submitted by more than one agency, only one agency may be reimbursed for case management services.

Check here if the State child health program delivers services using a managed care delivery model. The State provides an assurance that its managed care contract(s) complies with the relevant provisions of section 1932 of the Act, including section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against

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Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. The State also assures that it will submit the contract(s) to the CMS Regional Office for review and approval. (Section 2103(f)(3))

Guidance: In Section 3.2., note that utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package.

Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after- hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42CFR 457.490(b))

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))

Utilization control mechanisms are in place for the ALL Kids program to ensure that children use only health care that is appropriate, medically necessary, and/or approved by the State or the participating health plan. In addition, policies are in place to assure that necessary care is delivered in a cost-effective and efficient manner according to the vendors’ medical necessity definition. The current Blue Cross Blue Shield policies are available upon request.

Before being approved for participation in the ALL Kids program, health plan vendors must develop and have in place utilization review policies and procedures, demand management, and disease state management mechanisms. Provider networks approved for the ALL Kids program are accepted based on evidence of the vendors’ provider credentialing policies, provider accessibility, cost- effectiveness, and efficiency.

Each ALL Kids PLUS authorizing state agency has a utilization review mechanism particular to that agency. Services approved for ALL Kids PLUS are those which are developmentally necessary and/or physically necessary. Reviewing the appropriate use of services is part of the case manager’s duties.

The Alabama Medicaid Agency applies the same utilization controls to the CHIP Medicaid expansion

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enrollees as it does to the entire Medicaid child book of business. 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:

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):

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4.1.6 Disability Status (so long as any standard relating to disability status does not restrict eligibility): Children will be eligible for ALL Kids regardless of disability. ALL Kids PLUS is available to children with special conditions/needs who are enrolled in ALL Kids. ALL Kids PLUS enrollment is restricted to services authorized and financed by PLUS participating agencies. However, if access to additional matching funds becomes available and/or the health needs of CSHCC/N change, authorized services will be revised to reflect these changes.

4.1.7 Access to or coverage under other health coverage:

A child is not eligible for ALL Kids if s/he has any other health insurance coverage or is eligible for Medicaid.

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 42 CFR 457.310 and 457.320 that are not addressed above. For instance: Comprehensive health coverage will be provided from conception to birth for those with family incomes up to and including 312% FPL, whose mothers do not have comprehensive coverage, and reside in select counties in Alabama (initially Montgomery, Macon and Russell). Comprehensive coverage will be provided to this population from the date of enrollment and will continue until the last day of the month in which the 60 day postpartum period has elapsed after the end of a pregnancy. The date of enrollment may be as early as the first day of maternity-related service provision even if the application is completed a few days after the service is received. In other cases coverage will begin on the date the application is received by the CHIP office. Prenatal care, labor and delivery and limited postpartum care are paid using a bundled payment. In addition to the bundled payment, the state will provide comprehensive coverage during the postpartum period through ALL Babies HSI Initiative. For example, if a woman gives birth on June 26, benefits covered in the bundled package or postpartum HSI would end on August 31. Obstetric coverage for current ALL Kids members includes all prenatal care through 90 days postpartum and is billed as a bundled payment. Social Security numbers for the babies will not be required unless and until the child is born and applies for renewal.

Guidance: States may only require the SSN of the child who is applying for coverage. If SSNs are required and the State covers unborn children, indicate that the unborn children are exempt from providing a SSN. Other standards include, but are not limited to presumptive eligibility and deemed newborns.

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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); (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;

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(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 (8U.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, at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination, that the individual continues to

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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.

4.3. Methodology. Describe the methods of establishing and continuing eligibility and

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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) Superseded by ACA SPA 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))

There are no public notice state laws regarding enrollment caps and waiting lists in CHIP. Due to insufficient state funds, ALL Kids initiated a waiting list beginning with all new enrollees who would have had an effective date October 1, 2003. Public and enrollee notices about the waiting list were issued during the month of September 2003 prior to the impact of the waiting list. On August 23, 2004, ALL Kids reopened enrollment and discontinued use of the waiting list.

If during the year funds are not available at sufficient levels for coverage of children and funding is projected to be depleted before the end of the fiscal year, it is the State’s intent to place eligible children on a waiting list until adequate funding becomes available to resume enrollment. Alabama will provide public notice through press releases, written communication with stakeholders and stakeholder groups, presentations, and written communication from the program to all applicant families whose child(ren) is/are placed on the waiting list.

When a waiting list is implemented, the program has and will continue to receive new applications. These applications will be screened for Medicaid eligibility and then reviewed for ALL Kids eligibility. If a child is eligible for Medicaid, the child will be enrolled in Medicaid. Each family whose child is placed on the ALL Kids waiting list will be notified, by letter, of this placement. The notification letter will also contain information stating that the parent may wish to contact Medicaid if his situation changes and he believes that his child may be eligible for Medicaid. If the child remains on the waiting list for longer than three (3) months, the family will be periodically notified via letter that the child’s name is still on the waiting list.

If the State is using a waiting list, children will be enrolled on ALL Kids from the waiting list on a first on–first off basis as funding permits. When attrition has lowered program enrollment to a level at which there are sufficient state funds to re-open enrollment,

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children will be removed from the waiting list ( on a first on first off basis) and enrolled in ALL Kids. Children who are removed from the waiting list whose application information is greater than 90 days old will be asked to complete a form updating changes in information on their family size, income, and other points of eligibility. Upon receipt of the form, ALL Kids enrollment staff will evaluate the child’s eligibility for ALL Kids. Then, if eligible, either the child will be enrolled in ALL Kids or Medicaid and the family will be notified.

Children who have current enrollment in ALL Kids will be allowed to continue to renew their enrollment as long as they continue to meet all points of eligibility and have their renewal forms submitted and premium balances paid in full within 90 days after the date of termination. 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-ELAlso indicate whether the Express Lane option is applied to (1) initial eligibility determination, (2) redetermination, or (3) both.

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

4.3.3.3-ELList the components/components of CHIP eligibility that are determined under the Express Lane. In this section, specify any differences in

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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-ELList the component/components of CHIP eligibility that are determined under the Express Lane.

4.3.3.4-ELDescribe 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), 42CFR 457.350(a)(1) and 42 CFR 457.80(c)(3)) Confirm that the State does not apply a waiting period for pregnant women.

The State of Alabama assures that through enrollment screening processes, children whose

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applications are considered to be eligible for medical assistance under the State Medicaid plan will be referred for assistance under the appropriate plan. Additionally, ALL Kids eligibility staff query the Medicaid eligibility system to ensure applicants are not currently on any Medicaid program. All applications request the parent/guardian to provide the names and addresses of their employers. Eligibility staff screen all applications to ensure applicant children are not currently covered under group health insurance and have not voluntarily terminated group coverage within the last three months. In an effort to further minimize crowd-out, ALL Kids receives a daily “error report” which indicates children who have current BCBS health insurance or have terminated a BCBS policy within the last three months. In addition, quality assurance reviews are conducted on a sample of ALL Kids enrollees. Redetermination is completed every 12 months.

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)).

When a child’s application is reviewed by ALL Kids and determined to be eligible for Medicaid, ALL Kids enrolls the child in Medicaid. Because a joint application is used, no additional form is required to be completed. Parents are notified by ALL regarding this determination

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))

ALL Kids and Medicaid have a joint eligibility and enrollment system. When a Medicaid enrollment worker determines that a child is ineligible for Medicaid and eligible for ALL Kids, the worker enrolls the child in ALL Kids. Coverage is based on the application receipt date at the Medicaid office or the child’s last date of Medicaid or ALL Kids coverage. ALL Kids staff work very closely with the Medicaid central office and Medicaid enrollment workers to ensure that the policies and procedures of both agencies reflect the agencies’ desires for seamless transitions between the two agencies.

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

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4.4.5. Child health assistance is provided to targeted low-income children in the State who are American Indian and Alaska Native. (Section2102(b)(3)(D)) (42CFR 457.125(a))

The State of Alabama assures the provision of child health assistance to targeted low-income children in the State who are American Indians (as defined in section 4(c) of the Indian Health Care Improvement Act, 25 U.S.C. 1603(c)). As Stated in section 4.1, the ALL Kids program will provide Statewide coverage. No ALL Kids enrollee identified as being an American Indian will be charged a premium or co-pay. This policy extends to all children who identify themselves as an American Indian children whether they are a member of a federally recognized tribe or one of the eight state-only recognized tribes. Representatives from the Poarch Band of Creek Indians (the only federally recognized Tribe in Alabama) have assisted in the development of ALL Kids PLUS. Tribal children will have access to PLUS services.

CHIP staff meet and coordinate regularly with the Alabama Commission on Indian Affairs to ensure that Native American Children are identified and enrolled in ALL Kids. Additionally, a Native American was hired under a one-year contract to consult with ALL Kids staff and develop a comprehensive strategy to outreach to Native American children.

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

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

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

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

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

Section 5. Outreach and Coordination

5.1. (formerly 2.2)Describe the current State efforts to provide or obtain creditable health coverage for uninsured children by addressing sections 5.1.1 and 5.1.2.(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):

In Alabama, thanks to outreach efforts of a variety of public and private agencies and organizations, there is a high awareness level of children’s health insurance programs and their eligibility requirements. Over one-fourth of children under the age of 19 in Alabama are covered by Medicaid or ALL Kids. The programs are reaching children who might not otherwise have access to the health care they need.

Prior to CHIP, the Medicaid Program was the only public health insurance program for children in Alabama. Health services are provided in Alabama to uninsured and Medicaid enrolled children by private physicians, the 67 Alabama Department of Public Health (ADPH) county health departments, 16 primary care centers (including Federally Qualified Health Centers), two children’s hospitals (The Children’s Hospital of Alabama and Women’s and Children’s Hospital at the University of South Alabama) school health nurses, and one Indian Health Service Clinic. In addition to the two children’s hospitals, Alabama Department of Rehabilitation Services, Children’s Rehabilitation Services (CRS) provides specialty care to uninsured and Medicaid enrolled children with special health care needs. As lead agency for Alabama’s Early Intervention System, this agency coordinates services for infants and toddlers eligible for IDEA (Individuals with Disabilities Education Act), part C. This section describes the current efforts made by the ADPH to provide health care services, and to identify and enroll uncovered children in the Medicaid and ALL Kids programs. This section also describes the efforts made by CRS, the Alabama Medicaid Agency, the Alabama Department of Human Resources, and the Alabama Department of Mental Health and Mental Retardation to identify and enroll all uncovered children who are eligible to participate in the Medicaid and ALL Kids programs.

Alabama Department of Public Health

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As the CHIP lead agency, the ADPH is actively involved in all aspects of identification and enrollment of children who are eligible to participate in public health insurance programs and health insurance programs that involve public-private partnerships. Activities include the creation, publication, and distribution of marketing materials, management of the ALL Kids enrollment process, and targeted outreach activities for specific populations such as faith-based organizations, etc. The Alabama Department of Public Health provides some direct as well as support patient care for uninsured and Medicaid enrolled children and adolescents. Direct services for this population include: preventive child health services (well-child check-ups), prenatal services, Women Infants and Children Supplemental Nutrition [WIC] program services, preventive health education, immunizations, and Family Planning program services. Support services include case management services, the provision of information and referral via toll-free telephone lines, and laboratory services. These services are funded through federal Title V Maternal and Child Health Block Grant funds, federal Title X Family Planning program funds, federal WIC Program funds, Medicaid program reimbursements, federal immunization funds, state legislative appropriations, some local government appropriations, and a small amount of patient fee revenue. A variety of the above direct and support services are provided within ADPH county health departments. In fiscal year 2001, 34,664 children (birth through age 18 years) received health services in local county health departments. (This number excludes single service patients [STD-only, Immunization-only, WIC-only].) The Alabama Department of Public Health is the state’s Title V agency. Additionally, there are approximately 512 school health nurses, R.N.s and L.P.N.s, (working under the auspices of the ADPH, private hospitals, the Alabama State Department of Education, and/or local education agencies) in the state who provide a variety of health screening services, primary care and emergency services, Medicaid/ALL Kids enrollment facilitation, etc.

Income assessments are performed on all patients enrolled in ADPH clinics. The income assessments are reviewed for possible Medicaid eligibility. Beginning in FY 1991, Medicaid eligibility workers were out-stationed in health departments and other health care facilities to accept applications and complete Medicaid eligibility determinations at the time of health visits. A streamlined, four-page expanded Medicaid eligibility form, which was implemented in FY 1991, has been revised into a joint application with CHIP and the Alabama Child Caring Foundation (ACCF) and is available at county health departments. Out-stationed Medicaid eligibility personnel currently assist patients in completing the forms and data is put into an automated Medicaid system on-site. Final determination for Medicaid can then be made immediately. If the children appear to be ALL Kids or ACCF eligible the application is forwarded to the appropriate program.

New applications, as well as annual reviews of established patients, are assessed by ADPH intake staff and/or care coordinators for possible referral for medical assistance through Medicaid, ACCF, or SSI. When appropriate, staff assist families in completing the application forms, making appointments, and gathering medical information. Out-stationed Medicaid eligibility workers are based in many ADPH clinics, hospitals, and primary care centers across

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the state. Additionally, two Medicaid outstationed workers and a clerk are now located in the CHIP office who process many ALL Kids referrals. A third worker will be added in FY 2003.

Cross training sessions with staff at many levels has improved interagency communication at the community level.

In order to provide additional outreach, the ADPH operates two toll-free telephone lines for use by the general public. The toll-free telephone lines (established prior to the implementation of CHIP and continued to the present) are known as Healthy Beginnings and Info Connection. Two integral parts of the information provided to callers, via these telephone lines, are information on Medicaid, ALL Kids, and ACCF eligibility and referrals to health providers who accept Medicaid-eligible children and Medicaid-eligible pregnant women. Referral services provided by the Healthy Beginnings and Info Connection staff members are expanded through consultation supplied by a host of additional professionals located within the ADPH. The toll-free number for Healthy Beginnings is 1-800-654-1385. The Info Connection number is 1-800-545-1098. Both lines are operational 24 hours a day, seven (7) days a week; office hours are from 8:30 A.M. to 4:30 P.M. each week day. The Healthy Beginnings and Info Connection lines are publicized statewide through newspapers, television, posters, and pamphlets. Presentations regarding the lines are conducted statewide to various organizations and agencies. The numbers are also published in Alabama South Central Bell telephone books. Additionally, with the implementation of CHIP, the CHIP unit maintains two toll-free telephone lines (888-373-5437 for enrollment and eligibility issues and 877-774-9521 for administrative issues). Finally, in addition to the above efforts, ALL Kids, Medicaid, and the Alabama Child Caring Foundation have developed a joint application and renewal form for use by all three programs. This enables families to be screened for eligibility for all three programs and facilitates referrals and timely enrollment in the appropriate program.

Alabama Department of Economic and Community Affairs (ADECA) ADECA notifies the ALL Kids regional staff when a plant or large business plans to close in the near future. ALL Kids regional staff present ALL Kids information and materials at employee meetings prior to the plant/business closing. In order to prevent gaps in health insurance coverage for the children of the employees of the plant/business, an ALL Kids policy was developed which provides for beginning ALL Kids coverage (for eligible children) the day after employer sponsored coverage ends if an application is received by the ALL Kids enrollment unit within 30 days after the plant/business closing.

Alabama Department of Rehabilitation Services Children’s Rehabilitation Service Children’s Rehabilitation Service (CRS) also has coordination agreements with the Alabama Medicaid Agency. (These contracts existed prior to CHIP and have continued to be in effect.) The Alabama Medicaid Agency contracted with CRS for the provision of specialty medical services, specialized therapy (such as physical, occupational, speech, etc) services, and case

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management services to children with special health care needs. With the implementation of ALL Kids, CRS clinics were added as preferred providers under the ALL Kids basic benefits package and the ALL Kids PLUS package.

New applications, as well as annual reviews of established patients, are assessed by CRS intake staff and/or care coordinators for possible referral for medical assistance through Medicaid, ALL Kids, ACCF, or SSI. When appropriate, staff assist families in completing the application forms, making appointments, and gathering medical information. Joint Medicaid/ALL Kids/ACCF eligibility forms are available in all CRS offices and clinics. As in the ADPH, cross training sessions with staff at many levels has improved interagency communication at the community level. Medicaid and ALL Kids information and outreach brochures and posters are available in every CRS office throughout the state.

Additionally, like the ADPH, CRS operates toll-free telephone lines for use by the general public. One line is operated at the state level in Montgomery and additional lines are located in each CRS district office. An integral part of the information provided to callers, via these telephone lines, is Medicaid, ALL Kids, and ACCF eligibility and referral information. CRS and Early Intervention (EI) have both completed database matches with ALL Kids files to identify children known to both programs. CHIP staff have participated in many staff trainings throughout the state to assist CRS and EI staff in outreach for ALL Kids, Medicaid, and ACCF.

Division of Early Intervention As the lead agency for Alabama’s early intervention system for infants and toddlers with developmental disabilities and their families, this unit provides a toll free Child Find telephone number for use by the general public and primary referral sources. Additional efforts for coordination are described in the PLUS sections of this document.

Medicaid Agency The Alabama Medicaid Agency has 135 eligibility workers in over 170 locations to enroll children eligible for SOBRA Medicaid whose the family’s income is at or below 100 percent of FPL (for children born after September 30, 1983) or 133 percent of the FPL (for children through age five). With the implementation of CHIP, 23 workers were added throughout the state. In March, 2002, two eligibility workers and a clerk were housed in the ALL Kids central office to review applications referred from the ALL Kids eligibility workers. In addition to the CHIP office, these workers are located in places children are likely to go to receive health care - - county health departments, Federally Qualified Health Centers and hospitals. Because workers are in the community, they can and do establish working relationships with public and private providers, social service agencies and others. For example, supervisors provide in- service training and education on Medicaid, ALL Kids, and ACCF eligibility to physicians, Head Start workers, day care centers, Human Resources staff and others. The Alabama Medicaid Agency also has 10 district offices located throughout the state that process

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applications for the elderly and the disabled population. The 80 eligibility workers and 20 supervisors advise applicants about other programs and refer the applicants to the proper office when they do not qualify for a disabled program. They also advise about programs for which other family members may be eligible. These district offices work closely with providers to keep them informed of all programs available through the Medicaid Agency.

Applications for Medicaid, ALL Kids, and ACCF are easily available to anyone who needs one. Applications are available not only from Medicaid workers but also at physicians’ offices, county offices of the Department of Human Resources and hospitals. All sources of the joint application (i.e., ADPH, CRS, etc.) allow a “mail-in” application process thereby allowing Medicaid to complete a phone interview instead of a face-to-face interview. Medicaid has a toll- free number for anyone to call to ask questions about Medicaid eligibility and find out where and how to apply. The number is 1-800-362-1504. Medicaid’s Web site contains information on Medicaid eligibility and is used by advocates to assist people who want to apply for Medicaid.

Through its Medical Care Advisory Committee and its Physicians Task Force, Medicaid receives guidance on ways to reach potential Medicaid eligibles. Medicaid staff regularly brief these groups, who represent both providers and consumers, on all facets of the Medicaid program, including eligibility. Both groups are kept informed of upcoming changes in the Medicaid program and encouraged to provide comments and suggestions. With welfare reform and the separation of Medicaid eligibility from eligibility for public assistance, the Alabama Medicaid Agency and the Department of Human Resources have developed new cooperative arrangements to assure that children in the state’s lowest income families have access to Medicaid. Applications may be completed through the mail with a telephone interview, thus eliminating the need for a face-to-face contact. Currently DHR workers assess their clients to determine whether they might be eligible for any Medicaid, ALL Kids, or ACCF program. Workers help to complete forms, gather information and make appointments as necessary. However, the enrollment function for this Medicaid program will be transferred from DHR to the Medicaid Agency within the coming year.

Outreach occurs after the birth of an infant to a Medicaid recipient. Following the birth of each newborn whose mother is a Medicaid recipient, the Alabama Medicaid Agency sends the infant's parent or guardian a pamphlet on the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program as well as a pamphlet on immunizations. When children are enrolled in the SSI Program, they are automatically enrolled in the Medicaid Program. Additionally, a brochure is sent to parents/guardians of all new SSI eligible children encouraging them to participate in the EPSDT program. In addition to these efforts, social workers within the ADPH conduct patient recruitment as a part of their case management activities. These recruitment efforts are conducted through community presentations and professional relationships with other State and local agencies which serve mothers and children.

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The Alabama Department of Human Resources and the Alabama Department of Mental Health and Mental Retardation also provide case management services for Medicaid children known to their agencies, in order to facilitate their enrollment in health services particularly mental health services through the Rehabilitation Option.

Through CHIP Phase I, the Alabama Medicaid Agency, working with the Alabama Department of Public Health, took several major steps to identify and enroll all uncovered children who were eligible to participate in this public health insurance program. New eligibility workers were hired and they, plus existing eligibility workers, were trained in CHIP eligibility criteria as well as other Medicaid eligibility criteria. These eligibility workers are outstationed in health departments, hospitals, community health centers, CHIP office, etc.

In order to streamline the CHIP/Medicaid enrollment process, the Alabama Medicaid Agency initiated continuous eligibility for all Medicaid children under the age of 19 years, on April 1, 1998. Continuous eligibility means that Medicaid enrolled children maintain their Medicaid coverage continuously for one year from enrollment or re-determination.

Additionally, numerous presentations, regarding CHIP, have been made by knowledgeable professionals who are members of the broad based CHIP Workgroup and CHIP staff. These presentations include addresses to education professionals, rural health groups, child care management agencies, parents of children with special health care needs, Indian Health Service staff, the general public, etc. Some specific activities include:

Notice to all Medicaid providers News releases and camera-ready materials for newspapers Articles published in newsletters of health care provider associations–Medical Association of the State of Alabama, Alabama Hospital Association, Alabama Dental Association, and others Television commercials Radio spots Brochures have been distributed to date for outstationed Medicaid workers, public health workers, county human resources workers, Early Intervention Coordinating Councils, Mental Health Centers, family services centers, primary health care centers, hospitals, advocacy and professional organization, and in the school system, principles and guidance counselors. Brochures distributed at state meetings of Alabama Conference of Social Work, Medical Association, American Academy of Pediatrics-Alabama Chapter, Alabama Dental Association, Family Practice doctors, and others Satellite conferences to provide information about the basic ALL Kids Program and instruction in completing the application. Distribution of applications and brochures to all public school systems, local health departments, welfare offices, hospitals, community health centers, physician and dentist offices, pharmacies, WIC clinics, and family law attorneys, etc.

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Public forums for parents and advocates of CSHCC/N (Children with Special Health Care Conditions/Needs)

With specific regard to the Conception to Birth expansion and the RIM HSI, the ADPH will provide information to pertinent providers, hospitals and programs serving the target population residing in the counties in which the expansion is implemented.

In addition to the above, the state has engaged in the following particular activities to promote ALL Kids PLUS. Originally, it was anticipated that ALL Kids PLUS would involve four state programs, Children’s Rehabilitation Service, Early Intervention, Mental Health/Mental Retardation, and Civitan International Research Center Sparks Clinics. After conducting database matches, reviews of Pediatric Health History information, claims data, through mutual agreement, Sparks determined that their services were being adequately reimbursed through the ALL Kids basic benefit package. Therefore, attention was focused on the remaining three agencies. Since that time, CHIP has entered into discussions with the Alabama Institute for the Deaf and Blind with regard to becoming an ALL Kids PLUS provider. CRS has had an active contract for the provision of PLUS services since October, 2000 and has served as a valuable partner in establishing protocols for the identification of ALL Kids enrollees in need of PLUS services and the identification of current clients in need of insurance coverage.

Initially it was anticipated that children would be identified for the PLUS program through an in-depth analysis of the Pediatric Health History and chart reviews. Practical experience has shown that this was not the most productive method of identification. Database matches were necessary as a first action to even identify ALL Kids enrollees who were being served by CRS. After this baseline was established, claims reviews were shown to be a more valuable mechanism in identifying children eligible for PLUS services than were chart reviews. This claims review revealed that a much smaller percentage of ALL Kids enrollees, than originally projected, were in need of services beyond those available in the basic benefits package. Program staff continually monitor feedback from providers and families regarding the need for additional services. This type of feedback and analysis has influenced the approaches that have been used with the other potential ALL Kids PLUS agencies. Through the activities of the regional ALL Kids staff, central office social work consultant, and customer service staff, ALL

Kids enrollees in need of these specialized services provided by ALL Kids PLUS agencies have been identified and referred as appropriate.

In August of 1999, the ADPH broadcasted a nationwide satellite conference to educate the provider community and other concerned individuals regarding ALL Kids PLUS. In addition, CHIP staff provided training on the PLUS program to CRS staff at regional meetings.

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Alabama Department of Human Resources (DHR) The DHR has continued to partner with the ADPH to communicate ALL Kids information to their county staffs. They have provided initial and continuing updates to county DHR staff as well as provided periodic shipments of applications, posters, etc. The DHR has also assisted with outreach efforts through its childcare management agencies and facilitated communication with licensed child day-care homes and centers.

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

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

There is only one health insurance program for children in Alabama that resembles a public- private partnership. This program is known as the Alabama Child Caring Foundation (ACCF) and is a part of Blue Cross Blue Shield. The Alabama Child Caring Foundation provides limited ambulatory health insurance to low income, non-Medicaid/non-ALL Kids, uninsured children under the age of 19 years who remain full-time students through grade 12. The program is funded through private donations and matching funds from Blue Cross Blue Shield. Outreach for this program is conducted through articles in Blue Cross Blue Shield publications and public service announcements in local newspapers, via television, and radio stations. The University of Alabama and Auburn University coaches’ television shows expressly advertise the Foundation. Case finding is conducted by school administrators, school nurses, day care operators, and others. Additionally referrals to the Foundation are received from the ALL Kids program, local offices of the ADPH, the Alabama Medicaid Agency, the Alabama Department of Human Resources, the Alabama Department of Industrial Relations Dislocated Workers program, individual health care providers, civic organizations, churches, Sunday School classes, other religious organizations, and from Foundation participants.

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

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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.

The State of Alabama assures coordination with other public and private programs providing creditable coverage for low-income children. The SOBRA Medicaid program, ALL Kids, and the Alabama Child Caring Foundation have developed and use joint application and renewal forms.

All applications received by the ALL Kids enrollment unit are screened for Medicaid eligibility. When a child is identified by an ALL Kids enrollment worker as potentially eligible for Medicaid, the family’s application is sent to a Medicaid enrollment worker. Medicaid then processes it. As stated previously, two Medicaid enrollment workers and one clerical worker are physically located within the ALL Kids enrollment unit. This process also works in the reverse (applications are sent from Medicaid to ALL Kids).

When a child is identified by an ALL Kids enrollment worker as not potentially eligible for the Medicaid or ALL Kids but potentially eligible for the Alabama Child Caring Foundation (ACCF), the family’s application is sent to ACCF which then processes it and the opposite is also true.

Because it is recognized that the eligibility and enrollment systems of these three programs are not as seamless as needed, ALL Kids employs a full time MSW staff person. This staff person has responsibility to assist families in overcoming obstacles related to eligibility, enrollment, claims, and referral for specialty services as needed. Additional responsibilities include development and maintenance of the ALL Kids policy manual.

In addition, the State coordinates with the ALL Kids PLUS authorizing agencies. See the previous section for a broader description of the collaboration.

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

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

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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)

Phase I - Medicaid Expansion This portion of the outreach section, as it pertains to Phase I of Alabama’s Title XXI program, consists solely of efforts that were targeted toward Medicaid eligibles who were born after September 30, 1983 and who are under 19 years of age. There were four primary avenues through which outreach was conducted. These avenues were (1) the use of existing outreach approaches, (2) an initiative to improve communication with and services for the state’s rapidly expanding Hispanic population, (3) an increase in the number of Medicaid eligibility workers, and (4) coordination with the State Medical Association and physicians to educate physicians and their potentially eligible patients. Detailed information regarding these efforts is available from CHIP upon request.

Phase II - ALL Kids Outreach for ALL Kids is conducted through coordinated Statewide and regional efforts and in each county through partnerships, contracts, and regional CHIP coordinators. These efforts consist of a three-pronged approach: (1) Statewide media campaigns and initiatives; (2) outreach conducted by multi-county regional workers and consultants; and, (3) outreach conducted through existing programs and agencies. The purposes of all of these activities is to build networks and coalitions of persons who can inform individuals about the availability of ALL Kids and what it has to offer, and assist individuals in completing application forms. Outreach is conducted by a variety of individuals and in a variety of settings. Each feature of the three-pronged outreach approach is described below:

• Statewide media campaigns and initiatives - The media campaigns focus on informing individuals about the availability of ALL Kids and what they have to offer as well as providing information regarding where applications or other information may be obtained. Additionally, ALL Kids staff attend a wide variety of association meetings and conferences to inform memberships of the availability of children’s health insurance. The staff have developed specialized outreach materials (from videos to informational brochures and flyers to specific handouts) for specific groups to meet their needs.

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Staff have exhibited at booths and presentations to the Medical Association of the State of Alabama, Alabama Chapter of the American Academy of Pediatrics, Family Practice Physicians, Dentists, Social Workers, Department of Human Resources staff, Mental Health staff, Family Law Judges, Hospitals, Hospital auxiliaries, WIC staff, Public Health Staff, etc.

• Outreach conducted by multi-county regional workers and consultants – since the Spring of 2002, ALL Kids consultants have been and/are employed throughout the state, to disseminate information about the program to develop coalitions and networks of local residents to assist individuals in completing and submitting applications. These regional coordinators, their supervisory directors, and consultants are many times based in the county health departments but also utilize numerous off-site locales and alternative working hours. • Outreach conducted through existing programs and agencies - Information about CHIP, applications, and application assistance are available through existing child-related programs such as the Child Care Management Agencies and their targeted child day care centers, Food Stamps, Maternal and Child Health Block Grant Program clinics, WIC clinics, community health centers, Indian Health Services, school nurse programs, school counselor programs, Early Intervention programs, other social service agencies, etc. These programs and agencies have successful histories of serving the target population and the CHIP program utilizes their contact with this population to broaden outreach efforts. Dissemination of CHIP information to these entities has been facilitated since representatives of these agencies and programs served on the CHIP Advisory Council and continue to be in contact with CHIP as stakeholders. • With specific regard to the Conception to Birth expansion and the RIM HSI, the ADPH will provide information to pertinent providers, hospitals and programs serving the target population residing in the counties in which the expansion is implemented.

Phase III - ALL Kids PLUS Outreach for this special population is conducted primarily by the ALL Kids PLUS authorizing agencies. Outreach includes educating primary and specialty care physicians regarding ALL Kids PLUS, identifying and contacting children who may need PLUS services through reviews of agency rolls and possible reviews of the pediatric health histories (part of the application process), contact with community health centers, etc. Information about ALL Kids PLUS is incorporated into all publications and presentations.

In an effort to continually improve the ALL Kids PLUS, CHIP staff continue to meet with the ALL Kids PLUS participating agencies to identify and resolve any problematic areas and to recruit additional participating agencies. PLUS agencies assist the CHIP staff in developing contracts, performance standards, and procedures for ongoing monitoring and oversight of the ALL Kids PLUS program.

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NOTE: The application form and other materials have been translated into Spanish. Additionally, the ALL Kids enrollment unit employs a Spanish-speaking staff member and a Hispanic consultant has been hired to develop a Hispanic outreach plan.

Effective Date: March 1, 2020 48 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: Checkbox 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)))

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6.1.1.3. HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

The benefit package offered by the health maintenance organization with the largest insured commercial, non-Medicaid enrollment of covered lives was selected after several well attended public meetings where the benefits of the three benchmark plans were compared with the assistance of the insurers/administrators for the three plans. The benefit plan was altered slightly to make it more appropriate for children’s needs.

In addition to the ALL Kids basic benefits package, additional benefits may be available for enrollees who have special needs. These additional benefits are known as ALL Kids PLUS benefits and are only available as prescribed by ALL Kids PLUS authorizing agencies. These decisions regarding what benefits are provided, the requirements for their receipt, and the provision of the benefits is under the auspices of the PLUS authorizing state agencies. These state agencies are those with which CHIP has a contract for the provision of ALL Kids PLUS services, those agencies that ordinarily serve children with special health care conditions and needs, and which provide the matching funds for federal CHIP funding

The ALL Kids benefits plan is described in the ALL Kids Summary Plan Description (SPD), which is available upon request. The benefit package for enrollees in the CHIP Medicaid expansion will be identical to other children enrolled in comprehensive Medicaid categories.

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

Effective Date: March 1, 2020 50 Approval Date:

described in 42 CFR 457.430: • coverage of prescription drugs, • mental health services, • vision services and • hearing services.

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

The actuarial report must be prepared by an individual who is a member of the American Academy of Actuaries. This report must be prepared in accordance with the principles and standards of the American Academy of Actuaries. In preparing the report, the actuary must use generally accepted actuarial principles and methodologies, use a standardized set of utilization and price factors, use a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan, apply the same principles and factors in comparing the value of different coverage (or categories of services), without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used, and take into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage. (Section 2103(a)(2))

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))

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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 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 that is the same as the benefits provided under the Medicaid State plan including Early Periodic Screening, Diagnostic, and Treatment (EPSDT).

6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver.

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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. In the second amendment to the Alabama CHIP State Plan, ALL Kids PLUS was established which provided additional benefits for children with special health care conditions/needs. Attachment A contains a detailed description of the ALL Kids PLUS component of CHIP.

6.1.4.5. Coverage that is the same as defined by existing comprehensive state- based coverage applicable only in New York, Pennsylvania, or Florida (under 42 CFR 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 coverage under one of the benchmark plans specified in 457.420, through the 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 in457.431 to determine actuarial equivalence.

6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Provide a sample of how the comparison will be done).

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

6.1.4.7. Other. (Describe) Comprehensive health coverage will be provided from conception to birth for those with family incomes up to and including 312% FPL, whose mothers do not have comprehensive coverage, and reside in geographic areas in Alabama where CHIP unborn coverage is available. Prenatal care, labor and delivery and limited postpartum care are paid using a bundled payment. In addition to the bundled payment, the state will provide comprehensive coverage during the postpartum period through ALL Babies HSI Initiative. Coverage begins upon enrollment and will continue

Effective Date: March 1, 2020 53 Approval Date:

until the last day of the month in which the 60 day postpartum period has elapsed after the end of a pregnancy. For example, if a woman gives birth on June 26, benefits covered in the bundled package or postpartum HSI would end on August 31. The first day without coverage would be September 1. The date of enrollment may be as early as the first day of maternity-related service provision even if the application is completed a few days after the service is received. In other cases coverage will begin on the date the application is received by the CHIP office. The definition of comprehensive coverage includes coverage for obstetrical benefits. If a pregnant woman has other coverage but the other coverage does not include obstetrical benefits, then the other coverage would be considered non-comprehensive, regardless of any other benefits it insures. In this circumstance, the pregnant woman would meet the criterion for not having comprehensive coverage.

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

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

6.2. The State elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490) A description of the scope, amount and duration of services covered under ALL Kids and ALL Kids PLUS, as well as any exclusions and limitations can be found in the ALL Kids Summary Plan Description (SPD) which is available upon request. Health insurance benefits provided to conception to birth enrollees will be identical to the health insurance benefits provided to any pregnant ALL Kids enrollee. The date of enrollment may be as early as the first day of maternity-related service provision even if the application is completed a few days after the service is received. In other cases coverage will begin on the date the application is received by the CHIP office. Prenatal care, labor and delivery and limited postpartum care are paid using a bundled payment. In addition to the bundled payment, the state will provide comprehensive coverage during the postpartum period through ALL Babies HSI Initiative. In geographic areas in Alabama where CHIP unborn coverage is available, coverage for bundled obstetrical benefits begins upon enrollment and will continue until the last day of the month in which the 60 day postpartum period has elapsed after the end of a pregnancy. For example, if a woman gives birth on June 26, benefits covered in the

Effective Date: March 1, 2020 54 Approval Date:

bundled package or postpartum HSI would end on August 31. The first day without coverage would be September 1.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Guidance: See guidance for Section 6.1.4.1 for 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 the box below.

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

Guidance: Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or rehabilitative service may be provided, whether in a facility,

Effective Date: March 1, 2020 56 Approval Date:

home, school, or other setting, if recognized by State law and only if the service is: 1) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as prescribed by State law; 2) performed under the general supervision or at the direction of a physician; or 3) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

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

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

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

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

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

6.2.31. Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28)) Transplantation Services Emergency and Urgent Care Services Skilled Nursing Services Vision Services 6.2-DC Dental Coverage(CHIPRA # 7, SHO # #09-012 issued October 7, 2009) The State will provide dental coverage to children through one of the following. Please update Sections 9.10 and 10.3-DC when electing this option. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5)):

6.2.1-DC State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT6) codes are included in the dental benefits: 1. Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must follow periodicity schedule) 2. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes: D1000-D1999) (must follow periodicity schedule)

Current Dental Terminology, © 2010 American Dental Association. All rights reserved.

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3. Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999) 4. Endodontic (i.e., root canals) (CDT codes: D3000-D3999) 5. Periodontic (treatment of gum disease) (CDT codes: D4000-D4999) 6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200-D6999) 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999) 9. Emergency Dental Services

ALL Kids utilizes the BCBS of Alabama preferred Dental Network. Reimbursement for services delivered to ALL Kids' enrollees is paid based on the preferred dental network fee schedule. All network dentists agree to accept this as payment in full, with the exception of enrollee co-pays (no copayments on preventive or diagnostic services).

When costs are expected to exceed $1500 for a calendar year, ALL Kids utilizes a prior authorization process to ensure medically necessary services are provided. Costs associated with diagnostic and preventive services are excluded from this $1500 threshold. The amount is calculated by totaling the amount paid in dental claims minus the amount paid for preventive and diagnostic dental services.

If an enrollee is in need of dental services beyond $1500 in a calendar year, providers are instructed to submit a predetermination request to BCBS. BCBS reviews all provider requests to determine dental necessity of services and ALL Kids provides final approval to pay for services exceeding $1500. Providers are familiar with this process and dentally necessary services are provided in a timely manner regardless of the time of year. There is no unnecessary carry-over of services that need immediate attention.

If a family would like to appeal the BCBS/ALL Kids decision regarding the application of “medically necessary,” there is an appeals process which is consistent with the requirements of 42 CFR 457.1160 (b) and in compliance with state laws, the Security Act of 1974 (ERISA) and all other applicable regulations of the Department of Labor Procedures. 6.2.1.1-DC Periodicity Schedule. The State has adopted the following periodicity schedule: State-developed Medicaid-specific American Academy of Pediatric Dentistry Other Nationally recognized periodicity schedule Other (description attached)

6.2.2-DC Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR 457.420)

6.2.2.1-DC FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked, attach copy of the dental supplemental plan benefits description and the

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applicable CDT7 codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2.2.2-DC State employee coverage; (Section 2103(c)(5)(C)(ii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2.2.3-DC HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2-DS Supplemental Dental Coverage- The State will provide dental coverage to children eligible for dental-only supplemental services. Children eligible for this option must receive the same dental services as provided to otherwise eligible CHIP children (Section 2110(b)(5)(C)(ii)). Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, and 9.10 when electing this option.

Guidance: Under Title XXI, pre-existing condition exclusions are not allowed, with the only exception being in relation to another law in existence (HIPAA/ERISA). Indicate that the plan adheres to this requirement by checking the applicable description.

In the event that the State provides benefits through a group health plan or group health coverage, or provides family coverage through a group health plan under a waiver (see Section 6.4.2.), pre-existing condition limits are allowed to the extent permitted by HIPAA/ERISA. If the State is contracting with a group health plan or provides benefits through group health coverage, describe briefly any limitations on pre-existing conditions. (Formerly 8.6.)

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

Current Dental Terminology, © 2010 American Dental Association. All rights reserved.

Effective Date: March 1, 2020 59 Approval Date:

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)

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.”

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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 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

Effective Date: March 1, 2020 61 Approval Date:

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))

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))

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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.

Benefit Classification Standards Used Inpatient Inpatient benefits are applied per the benefit plan to a registered inpatient bed patient in a hospital. Outpatient Outpatient benefits are applied per the benefit plan to a patient who is not a registered inpatient bed patient of a hospital. Pharmacy Pharmacy benefits are applied per the benefit plan and evidence based clinical criteria for use of medication, regardless of behavioral health or medical diagnosis. Emergency Services covered in connection with a medical condition that occur suddenly and without warning with symptoms which are so acute and severe as to require immediate medical attention.

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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.

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

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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))

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

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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 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

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the assurances related to the determination of the portion of total costs for medical/surgical benefits that are subject to either an annual or lifetime limit.

6.2.4.3.2.1- MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least1/3 and less than 2/3 of all medical/surgical benefits, the State assures the following (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 with42 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

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.

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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))

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

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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))

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

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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.

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

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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 Blue Cross Blue Shield of Alabama; New Directions (Behavioral Health Benefits Manager for BCBS); Prime Therapeutics (Pharmacy Benefits Manager for BCBS)

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

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Other Blue Cross Blue Shield of Alabama; New Directions (Behavioral Health Benefits Manager for BCBS); Prime Therapeutics (Pharmacy Benefits Manager for BCBS)

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)) (42 CFR 457.1005 and 457.1010)

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

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

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

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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))

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

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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 # 10-002issued 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? Yes No

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

6.4.3.1.1-PAProvide 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-PADescribe 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-PADescribe 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-PAProvide an assurance that the waiting period for children in premium assistance is the same as for those children in direct coverage (if State has a waiting period in place for children in direct CHIP coverage).

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

6.4.3.4.1-PADescribe 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-PADescribe 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-PADescribe the plan to establish an employer-family premium assistance purchasing pool.

6.6.3.5.2-PAProvide 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-PAProvide 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

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

Section 7. Quality and Appropriateness of Care

Guidance: Methods for Evaluating and Monitoring Quality- Methods to assure quality include the application of performance measures, quality standards consumer information strategies, and other quality improvement strategies.

Performance measurement strategies could include using measurements for external reporting either to the State or to consumers and for internal quality improvement purposes. They could be based on existing measurement sets that have undergone rigorous evaluation for their appropriateness (e.g., HEDIS). They may include the use of standardized member satisfaction surveys (e.g., CAHPS) to assess members’ experience of care along key dimensions such as access, satisfaction, and system performance.

Quality standards are often used to assure the presence of structural and process measures that promote quality and could include such approaches as: the use of external and periodic review of health plans by groups such as the National Committee for Quality Assurance; the establishment of standards related to consumer protection and quality such as those developed by the National Association of Insurance Commissioners; and the formation of an advisory group to the State or plan to facilitate consumer and community participation in the plan.

Information strategies could include: the disclosure of information to beneficiaries about their benefits under the plan and their rights and responsibilities; the provision of comparative information to consumers on the performance of available health plans and providers; and consumer education strategies on how to access and effectively use health insurance coverage to maximize quality of care.

Quality improvement strategies should include the establishment of quantified quality improvement goals for the plan or the State and provider education. Other strategies include specific purchasing specifications, ongoing contract monitoring mechanisms, focus groups, etc.

Where States use managed care organizations to deliver CHIP care, recent legal changes require the State to use managed care quality standards and quality strategies similar to those used in Medicaid managed care.

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Tools for Evaluating and Monitoring Quality- Tools and types of information available include, HEDIS (Health Employer Data Information Set) measures, CAHPS (Consumer Assessments of Health Plans Study) measures, vital statistics data, and State health registries (e.g., immunization registries).

Quality monitoring may be done by external quality review organizations, or, if the State wishes, internally by a State board or agency independent of the State CHIP Agency. Establishing grievance measures is also an important aspect of monitoring.

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.

Guidance: The State must specify the qualifications of entities that will provide coverage and the conditions of participation. States should also define the quality standard they are using, for example, NCQA Standards or other professional standards. Any description of the information strategies used should be linked to Section 9. (Section 2102(a)(7)(A)) (42CFR 457.495)

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. (Section 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.) The State utilizes the expertise within the University of Alabama at Birmingham (UAB) School of Public Health in the implementation of the assessment of the ALL Kids program. Quality and appropriateness of care is assessed through the use of surveys such as a new enrollee survey, a continuous enrollee survey, and a disenrollee survey. Both process measures as well as outcome measures are considered when assessing the quality and appropriateness of care. CHIP also reviews claims data for quality assessment. Among the items used in tracking are the use of several claims data indicators such as whether or not children truly have a "medical home"; how well they are adhering to the recommended scheduled well-child exams; whether or not they are appropriately immunized; whether or not non-trauma based emergency room use is going down; how referrals are being made and if specialty care and related services are being received; and, patterns of prescription drug use. The State is also considering using other databases that can provide general indicators of child health and well-being such as the State’s immunization registry, adolescent pregnancy rates and health care utilization patterns identifiable off birth certificates, and the results of child death review efforts. Alabama monitors customer/patient/provider satisfaction through the use of surveys and informal communications with families, advocacy groups, and providers.

In addition to these monitoring strategies, the State assures access to care through monitoring of the provider network and benefit package design. Program staff are actively involved in

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identifying new providers for the ALL Kids network and have been particularly involved in the addition of pediatric dentists, primary care nurse practitioners, community mental health centers and emergency transportation providers. Geographic distribution of providers is monitored and is crucial when decisions regarding vendor choice are made.

The ALL Kids benefits package requires preauthorization only for hospitalization services. Therefore, access to all primary care providers and specialists is open to all enrollees without referral. Claims data are monitored by program staff to ensure quality and appropriateness of care. In addition, the State employs a masters level social worker to assist families who are experiencing difficulties accessing necessary services due to benefit structure or provider geographic availability. This staff member works closely with case managers at the vendor to identify areas in need of attention and provides the State with recommendations for benefit plan adjustment and/or provider network issues.

The ALL Kids PLUS program coordinates the evaluation of quality and appropriateness of care with the ALL Kids PLUS authorizing agencies and CSHCC/N advocacy groups through collaboration with stakeholders. It is also anticipated that an evaluation of ALL Kids PLUS may become part of the UAB evaluation in the future.

7.1.1. Quality standards . Performance measurement

7.1.2 (a) CHIPRA Quality Core Set

7.1.2 (b) Other The State ensures quality through contracted performance measures. These measures have been adapted in conjunction with the standards recommended by the AAP.

7.1.3. Information strategies Vendors are required to provide key health indicators information.

7.1.4. Quality improvement strategies

The performance guarantees and provider recoupment policy were included in the RFP and are included in the contract with the health plan.

Guidance: Provide a brief description of methods to be used to assure access to covered services, including a description of how the State will assure the quality and appropriateness of the care provided. The State should consider whether there are sufficient providers of care for the newly enrolled populations and whether there is reasonable access to care. (Section 2102(a)(7)(B))

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7.2. Describe the methods used, including monitoring, to assure: (Section 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)) Access is monitored through a number of methods including the following: Periodic review of the number and types of providers by county Quarterly review of claims data Quarterly review of new enrollee, continuous enrollee, and disenrollee survey data Feedback from families via telephone, e-mail, and postal service mail Feedback from providers

Further, the state uses claims data to monitor well-baby care as is described in 7.1.

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)) Access is monitored through a number of methods including the following: Quarterly review of claims data Quarterly review of new enrollee, continuous enrollee, and disenrollee survey data Feedback from families via telephone, e-mail, and postal service mail Feedback from providers Feedback from the CHIP Social Work Consultant

Further, the state uses claims data to monitor emergency room use as is described in 7.1.

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)) Access is monitored through a number of methods including the following: Periodic review of the number and types of providers by county Quarterly review of claims data Quarterly review of new enrollee, continuous enrollee, and disenrollee survey data Feedback from families via telephone, e-mail, and post service mail Feedback from providers Feedback from CSHCC/N advocates and ALL Kids PLUS providers

The ALL Kids PLUS network includes State agencies that serve children with special health care needs/conditions and that contract with CHIP to provide state matching funds for ALL

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Kids enrollees who use PLUS services. Currently, Children Rehabilitation Services is the only active PLUS program. The PLUS agency provides ALL Kids children with an individual case manager who will monitor access to specialists and treatment.

In general, the Medicaid standards will be used to establish qualifications for ALL Kids PLUS case management staff. All case management staff will meet specific qualifications, including education, training and appropriate credentialing which will be established by the participating agencies.

In most circumstances, the agencies’ delivery systems are discrete and clear which program provides services for specific conditions. However, where there is potential for overlap in responsibilities, the determination of which agency will provide case management will be done based on the needs of the child with input from the family and by determining what is in the best interest of the child. The agencies using the case management process, will coordinate with each other, the child, the family, and the care providers in determining if a change in case management is needed.

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)) Exigent medical circumstances may require more rapid response according to the medical needs of the patient. The health plan vendor has policies in place to assure that prior authorization of health services are completed in accordance with state law or regulations promulgated by the Department of Labor. CHIP staff receive feedback from providers and enrollee families if time periods are exceeded. All prior authorization of health services is in accordance with state laws. Children enrolled in a Medicaid expansion are subject to the same prior authorization policies to which children enrolled in Medicaid’s other full service children’s programs are subject.

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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)) There will not be any cost sharing of any type for families who are Native Americans or Alaskan Natives. There will also not be any cost sharing of any type for families whose children are enrolled in a CHIP Medicaid expansion. For all other families cost sharing will be as follows in 8.2.1. and 8.2.3.:

8.2.1. Premiums:

There are three (3) categories of enrollees: No Fee (Native Americans and Alaskan Natives). Low-Fee (children with family incomes from the base (above 141% FPL) up to and including 156% FPL), and Fee (children with family incomes greater than 156% FPL up to and including 312% FPL). There is no cost sharing for children in the No Fee group. There is a $52 premium per child, per year for children in the Low-Fee group. There is a $104 premium per child, per year for children in the Fee group. Premiums can be paid in one payment or in

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periodic payments (weekly, monthly, quarterly…) throughout the year. A family’s total premium payments are limited to three times the individual premium rate (i.e. $156 or $312 depending upon the income level of the family). Enrollment data systems do not allow for a family to be billed in excess of these amounts. Outstanding premium balances may be waived at the State’s discretion for applicants/enrollees living or working in FEMA or Governor declared disaster areas.

Premiums will not be charged to those enrolled in the Conception to Birth expansion.

8.2.2. Deductibles: None 8.2.3. Coinsurance or copayments:

There are no copayments for preventive services. The only permitted copayments are:

Fee Group Low Fee Group Copayments Copayments (for (for Children Children with with Incomes Incomes up to and >156% FPL up including 156% to and including Service FPL) 312%)

Dental $5/visit $20.00/visit

Doctor’s office visits $3/visit $13.00/visit

Behavioral Health office visits $3/visit $13.00/visit

ER Services $6/facility charge $60.00/facility charge

Inpatient Services (Hospital) $200/confinement $200/confinement

Non-Emergency ER Services $6/visit $60.00/visit

Allergy Testing $6/lab visit $17.00/lab visit

Allergy Treatment $3/visit $12/visit

Ambulance $6/occurrence $100/occurrence

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Mental and Nervous (Inpatient) $200/confinement $200/confinement

Outpatient Surgical Facility $6/visit $100/visit

Substance Abuse (Inpatient) $200/confinement $200/confinement

X-ray (Outpatient Facility) $6/total x-rays in 1 visit $65/total x-rays in 1 visit

Therapies (Physical, Occupational, Speech) $3/visit $13/visit

Routine Eye Exam $3/visit $13/visit

$3/frames Eye Glasses and/or lenses $13/ frames and/or lenses

Chiropractic visits $2/visit $5/visit

In addition, a Generic Plus pharmacy benefit became effective October 1, 2012 for children in both the low fee and fee groups. Prescription drugs are divided into two groups: generic and preferred brands. The designation “preferred” is assigned by the third party administrator. The copayment schedule is as follows: Fee Group Copayments (for Children Low Fee Group with Incomes Copayments (for Children >156% FPL up with Incomes up to and to and including including 156% FPL) 312%) Generic $1.00 $5.00 Preferred Brands $5.00 $25.00

For those enrolled in the Conception to Birth expansion, copayments will be assessed for the services and pharmacy as indicated in the above tables. Copayment amounts will be based on family income as noted below:

0% FPL up to and including 146% FPL - No copayment requirements From >147% FPL up to and including 156% FPL - assigned to the Low Fee copayment structure From >156% FPL up to and including 312% FPL – assigned to the Fee Group copayment structure 8.2.4. Other:

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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 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)) All enrollees are provided with coverage and cost-sharing information at initial enrollment through mailed documents. Additionally, this information is available online. All enrollees are notified of cost-sharing changes through letters mailed directly to the residence addresses on file with CHIP. In addition all stakeholders, including provider organizations/associations and state agencies, are notified by letter or other appropriate means of communication (i.e. email, fax notifications, and/or meetings) when changes are made to cost-sharing requirements. CHIP staff and customer service representatives are trained to discuss cost-sharing requirements with families, including premiums, copayments, and the annual out of pocket expenses limit.

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))

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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: inpatient, outpatient, prescription drugs, emergency room) Inpatient, outpatient, prescription drugs and emergency room

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

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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))

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))

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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))

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))

Alabama ensures that the annual aggregate cost-sharing for a family does not exceed five percent (5%) of a family’s income as is required by Section 2103(3)(B) of Title XXI. In addition, cost sharing, both premiums and copayments are in compliance with CHIP regulations.

There is minimal cost sharing for families, other than Native Americans and Alaskan Natives who have no cost sharing. No family is charged for more than three (3) premiums even if the family has more than three children.

To protect families against excessive medical expenses and comply with the statutory limit of no more than five percent of family income being expended on cost sharing expenses, families will be notified in writing, at initial enrollment and renewal, of the annual out of pocket maximum. Families are informed of this policy through educational literature. Also, CHIP staff and partners are trained to educate families about the limit on out of pocket expenses. Families are encouraged to keep receipts for all copayments and premiums so that once the out of pocket maximum is reached they will have the necessary documentation to stop cost-sharing. If a family reaches this limit and notifies the ALL Kids program, ALL Kids will review the case and if the limit has been reached new insurance cards will be issued stating that the child(ren) are not subject to further co-pays for the coverage period.

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) If a child is identified on an application as an American Indian, the enrollment worker

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automatically places the child in the no-fee category if the child becomes enrolled. Therefore the insurance vendor sends an insurance card, to the family, which indicates that the child is not subject to any co-pays.

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)) Superseded by ACA SPA Guidance: Section 8.7.1is 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))

ALL Kids has an annual premium for those in cost sharing categories. Upon enrollment, families are notified, by letter, that premiums are due. Enrollees have the entire 12-month coverage period to pay premium balances and receipt of benefits is not contingent upon payment of premiums. Current enrollees are not terminated for non-payment of premium during the 12-month coverage period. At one month, four months, seven months, and 10 months, families are notified of outstanding premium balances. They are notified, every notice for past-due premiums and cost-sharing, that, in most circumstances, premiums must be paid in full for ALL Kids coverage to be renewed. If a renewal application is received within 90 days past the coverage end date (and the premium is paid no later than 90 days past the coverage end date), enrollees may renew with no lapse in coverage.

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))

The amount of family income written on the renewal form is reviewed by enrollment workers at the time of renewal. If it is known to ALL Kids that a family is experiencing financial difficulty, the ALL Kids Social Work Consultant and/or ALL Kids Regional staff may assist

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the family in locating assistance for premium payment. Non-payment of premiums is forgiven if the family provides proof of bankruptcy status during the enrollment period or if the family has been affected by disaster events (living or working in FEMA or Governor declared disaster areas at the time of a disaster event).

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)) At the time of renewal, if the family’s income has dropped but is still above the Medicaid eligibility level, if the decision is made to forgive the unpaid premium(s), the child is renewed and placed in the appropriate ALL Kids category. If a family’s income has dropped below the ALL Kids eligibility, the child’s application is reviewed for Medicaid eligibility and, if the child meets all eligibility requirements, s/he is enrolled in Medicaid.

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))

This type of grievance is handled in the same impartial manner in which other grievances are handled as described in Attachment A.

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, copayments, 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)

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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))

1. The number of low-income (<200% FPL), uninsured children in AL will be reduced each year.

2. Given available funding, the number of low income (between the Medicaid eligibility upper income levels and 200% FPL), children enrolled in ALL Kids will be maintained at at least 50,000 (current enrollment) at any given time.

3. The number of low-income children (incomes in the Medicaid income eligibility ranges) enrolled in SOBRA Medicaid will be maintained at at least 300,000.

4. Enrollment in ALL Kids will result in more children having a medical home.

5. Enrollment in ALL Kids will result in a higher usage of preventive care.

6. Specialty services beyond the basic ALL Kids coverage package will be available for ALL Kids enrolled children with special health care needs.

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)) 1. Performance Goals for Objective 1: a. The number of low-income uninsured children in AL will be reduced by 1% each year until the number of low-income uninsured children is no larger than 10% of the children in the state. b. A tracking system will be established by April 2004, which will track applicants referred among ALL Kids, SOBRA Medicaid, and the Alabama Child Caring Foundation.

2. Performance Goals for Objective 2

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a. The percentage of families who do not renew their children’s ALL Kids coverage due to a financial barrier (owing past premiums) will not be more than 3% annually. b. A higher percentage of families with ALL Kids enrolled child(ren), report that financial barriers to accessing care have been reduced since enrollment in ALL Kids in comparison to the time before enrollment in ALL Kids. c. Plans which target outreach activities toward specific populations: (adolescents, Native Americans, and faith-based organizations) will be developed by October, 2002. d. Plans which target outreach activities toward specific populations: (adolescents, Native Americans, and faith-based organizations) will be implemented each year beginning with FY 2003. e. Plans which target outreach activities toward Hispanics, birth-to-five care providers, and Native Americans will be developed by January 1, 2004. f. Plans which target outreach activities toward Hispanics, birth-to-five care providers, and Native Americans will be implemented each year beginning with FY 2005. g. Plans which target outreach activities toward specific populations (other than adolescents, faith-based organizations, Hispanics, birth-to-five care providers, and Native Americans) will be developed and implemented as data or other information indicate. h. Language and culture will not be barriers to enrollment or renewal as evidenced by the availability of telephone assistance in the customers’ preferred languages, brochures and forms in both English and Spanish, and the availability of Spanish speaking, culturally competent customer service staff. i. There will be an incremental reduction from year to year, in the percentage of children canceling ALL Kids coverage due to nonparticipation in the renewal process.

3. Performance Goal for Objective 3: There will be maintenance of effort or an increase, on the part of CHIP, to decrease the number of uninsured low-income (Medicaid eligible) children as evidenced by at least the following: i. Continued use of a joint application form. ii. Continued use of a joint renewal form iii. Continued referral, without any barriers, of applications and renewals between ALL Kids and SOBRA Medicaid iv. Continued outreach efforts by CHIP staff for network building with community groups, professionals (individually and in groups), child care providers, schools, etc.

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v. Continued evaluation and monitoring of the application transfer/referral process between ALL Kids and Medicaid. vi. Continued computer enhancements to improve the communication with other agencies and current and potential ALL Kids enrollees.

4. Performance Goals for Objective 4: a. A higher percentage of families report that their ALL Kids enrolled child(ren) have a usual source of care since enrollment in ALL Kids than before enrollment in ALL Kids. b. A lower percentage of families report that their ALL Kids enrolled child(ren) have used a hospital emergency room since enrollment in ALL Kids than before enrollment in ALL Kids.

5. Performance Goals for Objective 5 a. A higher percentage of families report that their ALL Kids enrolled child(ren) have had a well child check-up in the past year since enrollment in ALL Kids than before enrollment in ALL Kids. b. A higher percentage of families report that their ALL Kids enrolled child(ren) have had a dental visit in the past year since enrollment in ALL Kids than before enrollment in ALL Kids. c. A higher percentage of families report that their ALL Kids enrolled child(ren) have had a vision screening in the past year since enrollment in ALL Kids than before enrollment in ALL Kids.

6. Performance Goal for Objective 6: a. Contracts with state agencies which serve children with special health care needs will be maintained for the purpose of providing specialty services beyond the basic ALL Kids coverage package for these children. b. Exploration of the feasibility of establishing contracts with other state agencies that serve children with special health care needs. c. Continued monitoring of access to specialty care for children with special health care needs.

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.

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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 457.710(d)) Assurance of an Objective Means for Measuring Performance To ensure an objective evaluation which can be independently verified, the evaluation will be based upon data bases which contain quantifiable information. These databases will, to the extent possible, contain numeric data. The ADPH will develop and/or direct the development of needed databases which do not currently exist. Since evaluation of some performance measures does not lend itself to numeric summation, measurement of these aspects of the plan will be based on review of a completed work plan which requires conclusive documentation. All data and documentation will be auditable. At periodic intervals, a formal comparison of program performance to the goals and measures set forth in this document or its subsequent amendments will be conducted. The CHIP staff directly responsible for the implementation of the program will conduct information comparisons of performance to these goals and measures on an ongoing basis. In this way, the program will be continuously monitored and activities may be adjusted so that the program may achieve its objectives.

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Measure of Performance: MEASURE ROUGH DEFINITION OF MEASURE

Reducing the Number of Uninsured Number of Uninsured CPS and/or NSAF and state data survey Tracking System Documentation that a tracking system exists and is used for 100% of the applications that are referred among ALL Kids, Medicaid, and Alabama Child Caring Foundation Related to SCHIP Enrollment Percentage of families not renewing due Renewal database – comparison of number of non- to owing past premiums renewals who owed premiums to the number who were due to renew. Percentage of families reporting a New enrollee survey database – comparison of percentage reduction in financial barriers to of reports indicating a reduction in financial barriers to accessing health care obtaining health care post-ALL Kids to pre-ALL Kids Development of plans to target outreach Documentation of development of these plans on file to adolescents, faith-based organizations Implementation of plans to target Documentation of implementation of these plans on file outreach to adolescents, faith-based organizations Development of plans to target outreach Documentation of development of these plans on file to Hispanics, Native Americans, and birth-to-five providers

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Implementation of plans to target Documentation of implementation of these plans on file outreach to Hispanics Native Americans, and birth-to-five providers Development and implementation of Documentation of development and implementation of plans to target outreach to other these plans on file groups Elimination of language and culture Spanish and English brochures and applications forms on barriers file

Employment of bi-lingual customer service staff

ALL Kids Customer service telephone operators are aware of and know how to use a telephone translating service. Reduction in percentage of children Enrollment Data Management system – Comparison of canceling ALL Kids due to number of enrollees who did not participate in the renewal nonparticipation in the renewal process to those due to renew. process Related to increasing Medicaid Enrollment Maintenance of effort with regard to: Use of a joint application form A joint SOBRA Medicaid and ALL Kids application form is in use Use of a joint renewal form A joint SOBRA Medicaid and ALL Kids renewal form is in use

Seamless referral between ALL Seamless referral policy in place Kids and SOBRA Medicaid

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Continued outreach effort Outreach/Marketing files reflect outreach conducted by central office staff, regional staff, and federal program office. Evaluation of application transfer Evaluation on files of meeting minutes and referral process Continued computer Computer enhancements will be in place. enhancements Related to increasing access to care Reported usual source of care New Enrollees Survey Reported ER use New Enrollees Survey Related to use of preventive care Reported use of well-child check-up New Enrollees Survey Reported dental visit New Enrollees Survey Reported vision screening New Enrollees Survey Other

Specialty service availability Contract(s) on file

Exploration of feasibility for Documentation on file (central office files and/or establishing contracts with other regional coordinator files) CSHCN state agencies

Monitoring access to care for CSHCN New Enrollees Survey

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Check the applicable suggested performance measurements listed below that the State plans to use: (Section 2107(a)(4)) 9.3.1. The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2. The reduction in the percentage of uninsured children. 9.3.3. The increase in the percentage of children with a usual source of care. 9.3.4. The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5. HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6. Other child appropriate measurement set. List or describe the set used.

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

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)

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Alabama assures it will comply with the annual assessment and evaluation required under Section 10. On an annual basis, the Alabama will review its operations, progress made in reducing the number of uncovered low-income children, progress made in meeting the goals and objectives stated in 9.1 and 9.2 of this document, and its compliance with applicable Federal laws and regulations. Section 9.3 states how Alabama will measure the goals and objectives in sections 9.1 and 9.2. Examples of data sources are: Census data, private foundation garnered data, data gathered via special surveys, utilization data from claims reports, enrollee family feedback from surveys, etc. The assessment will occur during the three months after the end of the fiscal year and a report of this assessment will be submitted to the Secretary by January 1 following the end of the fiscal 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) Alabama assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit.

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)) Alabama assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed

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

9.8.1. Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2. Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3. Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4. Section 1132 (relating to periods within which claims must be filed)

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

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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))

Efforts were made to make the process of developing the design and implementation of the Children’s Health Insurance Program inclusive. News coverage about the advocacy of the Children’s Health Insurance Program was provided regularly starting at the time that the issue came before the Alabama Legislature.

Formalized CHIP development groups were the CHIP Commission and the CHIP Task Force Work Groups. The CHIP Commission met three times, October 7, November 12 and December 17, 1998. The CHIP Task Force Work Groups met twelve times beginning August 6, 1998, and split into subcommittees to develop proposals in the following areas: (1) benefits, (2) eligibility, outreach and enrollment, and (3) funding. These subcommittee meetings were open to interested individuals and groups. At least three news conferences were held by the State Health Officer and/or the Medicaid Commissioner.

Public awareness was promoted through means such as television programs. Interested organizations such as Alabama ARISE, the Alabama Developmental Disabilities Planning Council, and Voices for Alabama’s Children were provided information for their membership about CHIP. Media coverage was provided and CHIP information has been made available on the Internet at: http://www.adph.org/allkids (formerly: http://www.alapubhealth.org) since October 2, 1998. During the first six and one-half month period of October 4 through April 21, 1998, 1,247 hits were made on this site specifically requesting CHIP information. This website includes a description of the program, a calendar of scheduled events, and an opportunity for interested persons to express their opinions about the program’s development. Order forms are available at every presentation. These forms enable participants to fax orders to the ALL Kids office and receive printed materials at no charge. The largest number of requests for information (312) came during the month of January. Newspaper editorials have praised the value of this program for our State’s children.

The CHIP Task Force Work Groups were comprised of employees of the Alabama Medicaid Agency, Public Health Department employees, and other interested parties including representatives of the Alabama Primary Care Association, Alabama ARISE, the Alabama Developmental Disabilities Planning Council, Voices for Alabama’s Children, the Alabama Child Caring Foundation, Alabama Dental Association, Alabama Hospital Association, Alabama Psychological Association, American Academy of Pediatrics-Alabama Chapter, Blue Cross Blue Shield, Children First, Children’s Health System, Children’s Hospital of Alabama, Family Voices, Health Maintenance Organization Association, Legislative Fiscal Office, Legislative Reference

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Service, Medical Association of the State of Alabama, University of Alabama at Birmingham, University of South Alabama, University of South Alabama Children’s and Women’s Hospital, United Health Care, as well as other State agencies including the Department of Education, the Department of Human Resources, the Department of Mental Health/Mental Retardation, State Employees’ Insurance Board, State Insurance Department, and the Department of Rehabilitation Services. These entities are now referred to as stakeholders and they continue to be involved as program changes are developed.

The Alabama program will continue to inform the general public about CHIP through the news media, to announce planning meetings, and to invite additional groups with an interest in being involved or informed as they become identified. There was extensive public involvement in the preparation of a comprehensive 133-page report which was released to the Alabama Legislature on January 12, 1998. In relation to the Governor’s Task Force on Children’s Health Insurance, periodic reports on the progress of recommendations contained the report are made. 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)) A meeting was held with representatives of the 2,176 member Poarch Band of Creek Indians, the only federally recognized Native American group in Alabama. Six other tribes are recognized by the State. The CHIP Program was explained and discussion centered on ways to coordinate CHIP and Indian Health Service-funded care, the role of traditional Native American healing, outreach methods for children and some demographics of the Poarch Band. Several presentations have been made to the Alabama Commission on Indian Affairs and CHIP staff meet and coordinate regularly with staff of the Commission. Other forms of outreach have included numerous presentations to the tribes, presence at Native American festivals throughout the state and the employment of a Native American consultant whose specific task was to develop a regionally- based outreach plan to the Native American population in Alabama.

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 CFR457.65(b) through (d).

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Alabama has no state law applicable to public notice of either cost sharing changes or waiting list implementations in CHIP.

Public Notice of Cost Sharing Changes: Specific public notice was given via a meeting of CHIP stakeholders in August 2003 and letters to enrollees’ families informing them of the changes in cost sharing. This meeting and the mailings followed much publicity in the state regarding the state’s financial situation and the possible impact on CHIP if a statewide referendum to raise taxes on (September 9, 2003) did not pass.

Public Notice of the Waiting List: ALL Kids initiated a waiting list beginning with all new enrollees who would have had an effective date October 1, 2003. Once the decision had been made to establish a waiting list, a press statement was released and letters were sent to stakeholders and other interested parties informing them of the institution of a waiting list and stressing the importance of returning renewal forms on time. Additionally, a letter to this effect was sent to every enrollee family along with a new insurance card(s). All of these notices were issued during the month of September 2003 prior to the impact of the waiting list.

On August 23, 2004, ALL Kids reopened enrollment and discontinued use of the waiting list.

If the State determines that it is again necessary to implement a waiting list, it will provide prior, appropriate public notice.

There are no public notice state laws regarding enrollment caps and waiting lists in SCHIP. 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.

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

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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

CHIP Budget STATE: AL FFY Budget Federal Fiscal Year 2021 State’s enhanced FMAP rate 80.81%

Benefit Costs Insurance payments 411,883,043 Managed care per member/per month rate 241 Fee for Service 411,883,043 Total Benefit Costs 418,883,043 (Offsetting beneficiary cost sharing payments) 7,000,000

Cost of Proposed SPA Changes – Benefit 0 Net Benefit Costs 411,883,043

Administration Costs Personnel 5,716,281

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STATE: AL FFY Budget General administration 6,923,267 Contractors/Brokers Claims Processing Outreach/marketing costs 500,000 Health Services Initiatives 501,250 Other 1,371,907 Total Administration Costs 15,012,705 10% Administrative Cap 44,987,005

Cost of Proposed SPA Changes 301,250

Federal Share 344,974,454 State Share 81,921,294 Total Costs of Approved CHIP Plan 426,895,748

NOTE: Include the costs associated with the current SPA.

The Source of State Share Funds: No state funds will be used.

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

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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.

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 collection program)

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.

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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. Alabama’s appeals process meets the requirements of the Program Specific Review as outlined in CFR.457.1120 – 457.1180. The ALL Kids appeals and grievance process can be found in Attachment A. The individuals involved in the Information review (first level) are not involved in the Administrative Review (second level) thus impartiality in the appeals process is provided. The individuals who conduct the Administrative Review are not involved in the Information Review process not in the original determination process. The review process for children enrolled in a CHIP Medicaid expansion is the same as the review process for children enrolled in other Medicaid full service children’s programs 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.

The State assures that the State laws or regulations are consistent with the intent of 42 CFR 457,1130(b). This grievance process for health service matters is provided by the insurance vendor and is in compliance with state laws, the Employee Retirement Income Security Act of 1974 (ERISA), and all other applicable regulations of the Department of Labor Procedures. A copy of the Blue Cross Blue Shield of Alabama appeals process can be found in the ALL Kids Summary Plan Description (SPD) which is available upon request. The grievance process for children enrolled in a CHIP Medicaid expansion is the same as the review process for children enrolled in other Medicaid full service children’s programs.

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.

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ATTACHMENT A

GRIEVANCE POLICY General Information

Applicants and enrollees of the ALL Kids Children’s Health Insurance Program (CHIP) have a right to discuss and question how eligibility for enrollment was determined. In particular they have the right to request review of program decisions concerning:

• Denial of eligibility • Failure to make a timely determination of eligibility • Suspension or termination of enrollment, including disenrollment for failure to pay premiums.

The ALL Kids Review Process has three levels of review--Information Review, Administrative Review and Formal Review. Requests for an Administrative Review and Formal Appeal must be submitted in writing. All correspondence with the applicant /enrollee concerning Administrative Review or Formal Review will be in writing.

ALL Kids Plus Services Requests for review of decisions made regarding eligibility for the ALL Kids Plus services must first be made to the ALL Kids Plus participating agency’s appropriate appeals process. This is necessary since eligibility for ALL Kids Plus is dependent on the participating agency’s eligibility criteria for services. Once the appeals process through the ALL Kids Plus participating agency has been exhausted, an appeal request may be made to the Children’s Health Insurance Program as described in ADPH ALL Kids Review Process.

Information Review In many cases problems can be handled informally through the Information Review Process without the need for a Administrative or Formal Review. CHIP staff is committed to using the Information Review process to provide a speedy and fair resolution when possible and appropriate.

Parents/designated representatives can initiate an Information Review via contact (telephone, e-mail or letter) with the Enrollment Unit supervisory staff, CHIP administrative staff, the CHIP social work consultant, CHIP regional staff, or interested agencies. Once the problem has been received, the appropriate staff will review the situation and initiate immediate action to resolve the problem and

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communicate the decision or resolution. If additional information is needed, the enrollee/applicant will be given the opportunity to provide clarification or submit additional information. Decisions made in the Information Review are usually provided within two working days. Notification to the applicant/enrollee will be communicated in the manner in which the request was made. Summation of the inquiry, review and resolution will be maintained on file and noted with the appropriate applicant/enrollee information.

If the problem remains unresolved in the eyes of the applicant/enrollee, they will be provided detailed information regarding their right to a Administrative Review, right to continued enrollment during the review process and provided copies of all forms and the procedures necessary to move forward through the review process. Appropriate notation will be kept in the applicant’s/enrollee’s electronic file noting the initial complaint, any information gathered during the Information Review, the decision reached through Information Review, the date of such decision and the applicant/enrollees intent to go forward with the Administrative Review Process.

Administrative Review In order to be considered, an Administrative Review Request Form must be received within ten (10) days of the final decision from the Information Review. The CHIP social work consultant will assist in gathering information that may clarify the request. All information on file from the Information Review and any information gathered by the CHIP Social Work consultant will be circulated to a three person Administrative Review Committee whose members were not involved in the Information Review process nor in the original determination process.

The applicant/enrollee will be notified in advance of the date and time that the Administrative Review Committee will be hearing information regarding their situation. They have the right to speak in person or have a representative of their choosing present during the review. They may also submit additional information and review program records and guidelines pertaining to the matter under grievance.

The Committee’s decision and the Program Director’s review of the decision must be completed within thirty-days (30) of receiving the Administrative Review Request Form. Applicant/enrollees will be notified in writing of the Administrative Review Committee’s decision within three working days of the decision. Additionally this notification will include the applicant/enrollee’s rights to continued review and the policy regarding a request for Formal Review by the State Health Officer.

If the grievance remains unresolved in the applicant/enrollee’s eyes, the applicant/enrollee may file a request for a Formal Review by the State Health Officer.

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Formal Review In order to be considered by the State Health Officer, a Request for Formal Review must be submitted to the CHIP office within ten (10) days of the final decision of the Administrative Review Committee. This request must be submitted on the Formal Review Request Form.

The applicant/enrollee will be notified in advance of the date and time that the State Health Officer will be hearing information regarding their case. Applicants/enrollees may appear in person or have a representative of their choosing to present information the State Health Officer. They may also submit additional information and review program records and guidelines pertaining to the matter under grievance.

Generally a decision will be issued within thirty-days (30) following receipt of the Request for Formal Review. Applicants/enrollees will be notified of the decision of the State Health Officer within three (3) working days of the decision.

The decision made by the State Health Officer is the final step in the administrative proceedings and will exhaust all administrative remedies.

Expedited Review If the enrollment or eligibility matter under review would worsen health conditions of the applicant/enrollee or jeopardize lives, an expedited CHIP review may be provided. An Expedited Review will be made within seventy-two (72) hours by quickly obtaining and reviewing information so as not to cause unnecessary harm to the applicant/enrollee.

Right for Continued Benefits During Appeals Process When the eligibility decision under review concerns renewal or re-determination of coverage, and the enrollee files a Request for Administrative Review, CHIP staff will ensure that coverage for that enrollee is continued until the review process is completed. The enrollee will be notified in writing of this continuation of coverage and their responsibility regarding any health services costs incurred if the resulting review decision supports termination of coverage. The enrollee will be issued a temporary health plan identification card with a coverage end date equal to the maximum length of time allowed for both the Administrative and Formal Review processes.

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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)

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CMS Regional Offices CMSRegion Associate Regional States Regional Office Address al Offices Administrator 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 4th 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- Iowa Missouri James G. Scott Richard Bulling Federal Bldg. Kansas City Kansas Nebraska james.scott1@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

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

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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

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language disorders. 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)

Effective Date: March 1, 2020 114 Approval Date:

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 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.

Effective Date: March 1, 2020 115 Approval Date:

This amendment implements a health services initiative (HSI) to provide comprehensive health coverage during the 60-day postpartum period to individuals whose pregnancies were covered under the Reducing Infant Mortality Conception to Birth program known as ALL Babies.

Approval Package

_____________________________________________________________________________

Table of Contents

State/Territory Name: Alabama

State Plan Amendment (SPA) #: AL-23-0026-RIM2

This file contains the following documents in the order listed:

1) Approval Letter 2) State Plan Pages

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

Children and Adults Health Programs Group

April 20, 2023

Ms. Wanda Davis Deputy Director, Children's Health Insurance Program 201 Monroe Street Montgomery, AL 36104

Dear Ms. Davis:

Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number, AL- 23-0026-RIM2, submitted on February 1, 2023, has been approved. This SPA has an effective date of May 1, 2023.

Through this SPA, Alabama expands its ALL Babies coverage to an additional 33 counties (for a total of 36 counties). ALL Babies provides CHIP eligibility for children from conception to the end of pregnancy (also known as the “unborn” option) with family incomes up to and including 312 percent of the federal poverty level (FPL) whose pregnant parents are not otherwise eligible for Medicaid or CHIP. Coverage will include pregnancy-related services including prenatal care for children from conception to the end of pregnancy. A copy of the approved CS9 state plan page is attached to be incorporated into the state's approved CHIP state plan. This page supersedes the previous CS9 that was approved on September 17, 2019.

Also through this SPA, Alabama expands its health services initiative (HSI), the ALL Babies Postpartum Initiative, to the same additional 33 counties (for a total of 36 counties) to provide 60 days of postpartum coverage for birth parents previously covered under the ALL Babies program.

The HSI approval is based on section 2105(a)(l)(D)(ii) of the Social Security Act (the Act) and 42 CFR §§ 457.10 and 457.618, which authorize use of title XXI administrative funding for HSIs that improve the health of children, including targeted low-income children and other low-income children. Consistent with section 2105(c)(6)(B) of the Act and 42 CFR § 457.626, title XXI funds used to support an HSI cannot supplant Medicaid or other sources of federal funding.

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

Your Project Officer is Joshua Bougie. He is available to answer your questions concerning this amendment and other CHIP-related matters. His contact information is as follows:

Page 2 – Ms. Wanda Davis

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Telephone: (410) 786-8117 E-mail: joshua.bougie@cms.hhs.gov

If you have additional questions, please contact Meg Barry, Director, Division of State Coverage Programs, at (443) 934-2064. We look forward to continuing to work with you and your staff.

Sincerely, /Signed by Sarah deLone/

Sarah deLone Director

TEMPLATE FOR CHILD HEALTH PACWLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN'S HEAL TH INSURANCE PROGRAM

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

State/Territory: Alabama (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)) Scott Harris, State Health Officer, Alabama Department of Public Health (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)):

N,ame: Catherine Donald Position/Title: Acting CHIP Director Name: Shaundra B. Morris Position/Title: Director, ADPH Financial Services 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 0MB control number. The valid 0MB 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, 2022 1 Approval Date: January 13, 2023

Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 105-33amended 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 of2010 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 457as well as the previously approved SP A 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 SP A 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 SP As 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. ASP A 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

Effective Date: October 1, 2022 2 Approval Date: January 13, 2023

response is received. More information on the SP A 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)(l)); (42CFR 457.90) 6. Coverage Requirements for Children's Health Insurance- Regarding the required scope of

Effective Date: October 1, 2022 3 Approval Date: January 13, 2023

health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary­ approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State's use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The 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 210l(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

Effective Date: October I, 2022 4 Approval Date: January 13, 2023

benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

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

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SP A 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) • IO (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)

Effective Date: October 1, 2022 5 Approval Date: January 13, 2023

• 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 ofup 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 ofMedicaid, 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 ofProject 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, 2022 6 Approval Date: January 13, 2023

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)(l)); (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 XXL 1.1.1.0* Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(l) 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 SP A to CMS for review and approval. Providing expanded benefits under the State's Medicaid plan (Title XIX) (Section 1.1.2. D 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.S A combination of both above. (Section 2101(a)(2))

* Until October 1, 2002, Alabama's CHIP was a combination program. With the mandated gradual increase of Medicaid coverage at higher income levels for children born after September 30, 1983, the Medicaid expansion portion of CHIP was subsumed, on October 1, 2002, by the Alabama Medicaid SOBRA Program for Pregnant Women and Children.

The State will provide dental-only supplemental coverage. Only States operating a1.1-DS□ 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 211 0(b)(5)) 1.2.S 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))

Effective Date: October 1, 2022 7 Approval Date: January 13, 2023

Alabama has not and will not claim expenditures for child health assistance prior to the time that the State has legislative authority to operate the State 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. ( 42CFR 457 .130)

Assurances are on file with DHHS. The Alabama Department of Public Health continues to assure that compliance 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 SP A may have different implementation dates that must be after the effective date.

Original Plan Effective Date: February 1, 1998 Amendment 1 - Establishment of ALL Kids Effective Date: February 1, 1998 Implementation Date: October 1, 1998 Amendment 2 - Establishment of ALL Kids PLUS Effective/Implementation Date: October 1, 1999 Amendment 3 -Disregards Effective/Implementation Date: June 1, 2001 Amendment 4 - Compliance Effective/Implementation Date: August 24, 2001 Amendment 5- Waiting List, Cost Sharing, Benefit Changes Effective/Implementation Date: October 1, 2003 Amendment 6-Discontinuance of the Waiting List and other Clean-Up changes

Effective Date: October 1, 2022 8 Approval Date: January 13, 2023

Effective/Implementation Date: November 23, 2004 Amendment 7 - Raise the upper income eligibility limit to 300% of FPL and other minor changes Effective/Implementation Date: October 1, 2009 Amendment 8 -Include a private foundation grant as an additional source of state funding Effective/Implementation Date: October 27, 2009 Amendment 9 - Establishment of a Prospective Payment System for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) Effective/Implementation Date: October 1, 2009; Addendum on Dental Benefits Under Title XXI: Effective/Implementation Date: October 1, 1998 Amendment 10 -Eligibility for children of employees of a public agency (state employees and public education employees) Effective/Implementation Date: January 1, 2011 Amendment 11 - Provisions for Implementing Temporary Adjustments to Enrollment Determination and/or Redetermination Policies and Cost Sharing Requirements for Applicants/Renewals living in and/or working in FEMA or Governor declared disaster areas at the time of a disaster event. In the event of a disaster, the State will notify CMS of the intent to provide temporary adjustments to its enrollment and/or redetermination policies, the effective dates of such adjustments and the counties/areas impacted by the disaster. Effective/Implementation Date: April 15, 2011 Amendment 12 - Increase premiums, increase co-pays and revise the methodology for determining annual aggregate cost-sharing Effective/Implementation Date: May 1, 2012 Amendment 13-Establishment of copayments for therapy services (physical, occupational, and speech), vision services and chiropractic services; and cleanup changes Effective/Implementation Date: August 1, 2013 Amendment 14-Alignment of ALL Kids fee groups with provisions of the Affordable Care Act (ACA) and other editorial changes to comply with previously approved ACA SP As. Effective/Implementation Date: January 1, 2014 Amendment 15 - AL-16-0015-MEXP-(::HIP Medicaid expansion to cover Medicaid enrollees ages 14 years to 19 years with incomes above 18% FPL through 141% FPL. Effective Date: October 1, 2015 Implementation Date: January 1, 2016 Amendment 16 -AL-18-0016-P AR - Attestation and documentation of Mental

Effective Date: October 1, 2022 9 Approval Date: January 13, 2023

Health Parity and Addiction Equity. Submission Date: July 10, 2018 Effective Date: October 1, 2017* Implementation Date: October 1, 2017* *Note: Benefits were adjusted in October 2010 to be compliant with mental health parity; this amendment did not require any benefit changes Amendment 17 -AL-19-0017-RIM - Reducing Infant Mortality (RIM) Health Service Initiative Submission Date: July 17, 2019 Effective Date: July 1, 2019 Implementation Date: July 1, 2019 Amendment 18 -AL-19-0018-RIM CS9 Eligibility -Coverage From Conception to Birth Submission Date: July 17, 2019 Effective Date: July 1, 2019 Implementation Date: July 1, 2019 Amendment 19 -AL-20-0019-CEN CS15 MAGI-Based Income Methodologies -Temporary Income Submission Date: February 26, 2020 Effective Date: July 1, 2020 Implementation Date July 1, 2020 Amendment 20 -AL-20-0020-COVI Allowing for Temporary Waiving of cost sharing requirements for enrollees who reside and/or work in a State or Federally declared disaster area. Submission Date: July 29, 2020 Effective Date: March 1, 2020 Implementation Date: March 1, 2020 Amendment 21 - AL-20-0021-BH Documentation of AL CHIP compliance with the SUPPORT Act. Submission Date: July 29, 2020 Effective Date: October 1, 2019 Implementation Date: October 24, 2018 Amendment 22 -AL-21-0022-PP Postpartum coverage Health Services Initiative for ALL Babies Submission Date: May 13, 2021 Effective Date: July 1, 2021 Implementation Date: July 1, 2021 Amendment 23 -AL-22-0023-OBJ Edits to align Strategic Objectives and Performance Goals with

Effective Date: October 1, 2022 Approval Date: January 13, 2023

CARTS Submission Date: 3/30/2022 Effective Date: 10/1/2021 Implementation Date: 10/1/2021 Amendment 24 - AL-22-0024-ARP Coverage of COVID-19 vaccine, testing, and treatment under American Rescue Plan Act Submission Date: 3/30/2022 Effective Date: March 11, 2021 Implementation Date: March 11, 2021 Amendment 25 - AL-22-0025-CE 12-Month Postpartum Period Continuous Eligibility Submission Date: August 18, 2022 Effective Date: October 1, 2022 Implementation Date: October 1, 2022 Amendment 26 - AL-23-0026-RIM2 CS9 Eligibility - Statewide Coverage from Conception to Birth Submission Date: January 31, 2023 Effective Date: May 1, 2023 Implementation Date: May 1, 2023 Amendment 27 - AL-23-0027-CC Amending AL-19-0017-RIM to discontinue HSI Submission Date: January 31, 2023 Effective Date: October 1, 2023 Implementation Date: October 1, 2023

Effective Date: October 1, 2022 11 Approval Date: January 13, 2023

Transmittal Number SPA PDF Description Superseded Group # Plan Section(s) AL-14-0016 MAGI CS7 Eligibility - Targeted Low Supersedes the (Original: AL-14-0016 Eligibility Income Children current Effective/lmplementati & sections on Date: January 1, Methods Geographic 2014) Children With Access to Area 4.1.1; Age CS10 Public Employee Coverage 4.1.2; and Income 4.1.3 Section 4.4.1: Supersedes only the MAGI-Based Income information on AL-20-0019-CEN (affects only CS15) CS15 Methodologies dependents of public Effective employees in Implementation Date: this section; July 1, 2020 supporting documentation should be incorporated as an appendix to the current state plan

Incorporate within a separate subsection under section 4.3

AL-23-0026-RIM2 CS9 Coverage from Conception (Original: AL-19-0018- to Birth RIM Effective/Approval Date: July 1, 2019)

Effective Date: October 1, 2022 12 Approval Date: January 13, 2023

Transmittal Number SPA PDF Description Superseded Group # Plan Section(s) (Original: AL-14-0014 XXI CS3 Eligibility for Medicaid Supersedes the Effective/lmplementatio Medicaid Expansion Program current n Date:January 1, 2014) Expansio Medicaid n expansion AL-16-0015-MEXP CHIP Medicaid expansion section 4.0 to cover Medicaid Effective/lmplementati enrollees ages 14 years to on Date: October 1, 19 years with incomes 2015 above 18% FPL through 141% FPL AL-14-0015 Establish CS14 Children Ineligible for Incorporate 2101{f) Medicaid as a Result of the within a Effective/Implementati Group Elimination of Income separate on Date: January 1, Disregards subsection 2014 under section 4.1 AL-14-0018 Eligibility CS24 Single, Streamlined Supersedes the Process Application current Effective/lmplementati Screen and Enroll Process sections 4.3 on Date: January 1, Renewals and 4.4 2014 AL-14-0017 Non- CS17 Non-Financial Eligibility - Supersedes the Financial Residency current section Effective/Implementati Eligibility 4.1.5 Non-Financial - Citizenship on Date: January 1, CS18 2014 Supersedes the CS19 Non-Financial - Social current Security Number sections 4.1.0; 4.1.1-LR; 4.1.1- CS20 Substitution of Coverage LR CS21 Non-Payment of Premiums Supersedes the current section CS27 Continuous Eligibility 4.1.9.1

Effective Date: October 1, 2022 13 Approval Date: January 13, 2023

Transmittal Number SPA PDF Description Superseded Group # Plan Section(sl

Supersedes the current section 4.4.4

Supersedes the current section 8.7

Supersedes the current section 4.1.8

Effective Date: October 1, 2022 14 Approval Date: January 13, 2023

1.4-TC Tribal Consultation(Section 2107(e)(l)(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. In accordance with approved policies, on December 08, 2022, a certified letter explaining the changes proposed in AL-23-0026 and AL-23-0027 was mailed to theTribal Chairman of the one federally recognized Native American tribe in Alabama, the Poarch Band of Creek Indians. The letter included the purpose for the proposed changes and a description of the changes. In the letter, theTribal Chairman was also reminded that she had the opportunity to respond to the proposed changes within 30 days and was given contact information for any such response. The certified letter was signed by the CHIP Deputy Director. TN No: Approval Date Effective Date: January 09, 2023

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)(l)); (42 CFR 457.80(a)) Prior to CHIP, the only two programs offering health insurance to low-income children

Effective Date: October 1, 2022 15 Approval Date: January 13, 2023

were Medicaid and the Alabama Child Caring Foundation (ACCF). Medicaid served children at the minimum income levels required by federal law. This meant that Medicaid coverage was available to children at three different levels of income and age: -Those under the age of six (6) years with incomes up to 133% FPL; -Those children six (6) through 14 years of age who were born after September 30, 1983 with incomes up to 100%FPL; and, -Those remaining children through the age of 18 years (middle and older teens) with incomes at theTANF assistance level (below approximately 13% FPL). The ACCF served children (birth through 18 years) with incomes from the Medicaid levels up to 200% FPL.

From February 2, 1998 through September 30, 2002, Phase I of CIDP, a Medicaid expansion was in existence. On October 1, 2002, Phase I of Alabama's CHIP was subsumed by the Alabama SOBRA Medicaid Program. Beginning October 1, 2015, however, children in this category (ages 14 to 19 with incomes between 13% FPL and 141 % FPL) will again be enrolled in a CHIP Medicaid expansion.

Originally, CIDP used a baseline number of uninsured children derived from the Current Population Survey (CPS). This baseline including the following chart was derived from a study by Winterbottom et.al. based on a three year merged Current Population Survey, or CPS, (1990-92), which showed over 200,000 children, in Alabama, under 18 years to be uninsured.

Employer Medicaid Other Uninsured Covera2:e Percent 59.3 17.2 5.1 18.4 Number 652,300 189,200 110,000 202,400

However, due to concerns about the CPS regarding potential problems with subjects' abilities to recall information, Alabama changed its baseline estimate to reflect data from the 1997 round of the Urban Institute's National Survey of America's Families (NSAF). The NSAF indicated that there were 173,012 uninsured children in Alabama. Of these, 91,209 were P 100% Federal Poverty Level (FPL), 49,579 were above 100 up to 200% FPL and 32,223 were >200% FPL.

In its first 4 years of implementation (October 1, 1998 - September 30, 2002), Phase II, ALL Kids, enrolled over 80,000 children. It is estimated that 52,000 children have current enrollment in ALL Kids at the end of FY 2002.

ALL Kids PLUS, added as a third amendment to the CHIP State Plan (October, 1999), serves as a mechanism by which children with special health care needs/conditions (CSHCN/C), who are enrolled in ALL Kids, may receive health and health related services which are beyond the

Effective Date: October 1, 2022 16 Approval Date: January 13, 2023

scope of the basic ALL Kids package. ALL Kids PLUS was designed so that it serves as a funding source for CHIP state match and as a funding mechanism for state agencies who serve CSHCN/C with state funds. State agencies participating in ALL Kids PLUS supply the state match, provide the service, and receive full reimbursement. It was originally estimated that approximately 9% of these enrollees would also receive at least one service under ALL Kids PLUS. However because the basic benefit package is so comprehensive, a much lower percentage of children are receiving PLUS services. It is expected that this percentage will increase as more state agencies contract with CHIP to become ALL Kids PLUS providers. With the advent of ALL Kids, the ACCF has changed its income eligibility criteria to serve children who are not eligible for Medicaid or ALL Kids and who have incomes up to 235% FPL. Because, the ACCF has no enrollment restriction regarding immigrants, this program has seen a dramatic increase in its Hispanic enrollment.

Guidance: Section 2.2allows 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 at42 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)(l)(D)(ii)); (42 CFR 457.10) As peFmitted undeF seetion 210S(a)(l)(D)(ii) of the Soeial SeeuFity Aet and fedeFOI Fegulations at 42 CFR 457.10, the State of ,A,,lahama is implementing a health senriees initiatwe (HSI) that will use CHIP funds, within the fedeFOI administFative expendituFes eap allowed feF states, to support the Redueing Infant Mortality (RIM) Health Senriees Initiatiü;e. The aim of this initiative is to Feduee the infant mortality Fate in seleeted eounties within Alabama thFough the pFoivision of a ivaFiety of e"l'idenee based ease management senriees feF pFegnant women and ehildFen. These ease management senriees will taFget health, soeial, and hehavioFOI health Felated high Fisk faetoFs whieh h&\'e been shown to impaet pngnaney outeomes and infant health. Case Management senriees will eonneet patients, with high Fisk faetoFs, to appFopFiate senriees and ease manageFS will fellow up to ensuFe that Fisk faetoFs &Fe being addFessed satisfaetoFily. It is antieipated that the ease manageF will make a total of (, faee to faee visits. Thne visits would oeeuF duFing the pFenatal eaFe, and thFee visits would he pFovided post delivery.

The eaFe eooFdination senriees pFoivided postpartum ineluding senriees to the infant inelude:

i. Make home visit within one month fellowing deliveey to eomplete the fellowing: 1. EneauFOge patient ta keep postpartum appaietmeet inehuling pFa¥idieg appointmeet FemindeFs ta help ensuFe eompletian af the postpartum appointment. 2. EneouFage patieet to ehoose a Feliahle birth eontFol method. If the patient has ehosen

Effective Date: October 1, 2022 17 Approval Date: January 13, 2023

steriluetioe es her method, follow up with the patient to ensure the proeedure is eompleted. 3. Ensure patient is established withe PMP for the iefeet. 4. Ensure iefeet hes enrolled ie WIC, if eligible. S. Edueete the patient oe the importeeee of immueuetioes for the iefeet. ii. ,4,.ssist ie sehedulieg eppoietmeets with iefeet's PMP up to the first year to ensure that well hehy eheelmps ere made end immueuetioes ere up to date. Follow up after the eppoietmeets to verify that eppoietmeets were kept. Well Behy eheekups ere seheduled et: e. 1 month h. 2 months e. 4 months d. ft months e. 9 months f. 12 months HI. Promote the ehild's overall physieel, eogeitive, end emotioeel de¥elopmeet through edueetieg pereets/eeregi¥ers about developmental milestones eeeordieg to the ehild's ege end developmental abilities. iv. Complete ee ASQ 3 (Ages end Stages Questioeeeire, Third Edition, e developmental sereeeieg tool) es appropriate et feee to feee eppoietmeets. v. Edueete the parents about the importeeee of reeding to the iefeet to promote eogeiti'ie de¥elopmeet. vi. Mek:e referrels for the ehild, es appropriate, sueh es Early Ieterveetioe, Children's Rehehilitetioe Sen'iees, ete. ¥ii. Prior to the ehild's first birthday, ensure he/she is established withe dentist. viii. Sereee the mother for post pertum depression et eeeh feee to feee ¥isit end meli,e referrals end fellaÌ, up (es needed)

With the eneptioe of pro¥idieg eeeessery preeetel monitoring by e nurse ie the home or health department setting, ea HSI funds will he spent oe direet eere.

The high risk: feetors that HSI will address ieelude the folloÌ'ieg: ACEs Seore of Í4 Depressioe1 Diabetes Mellitus Current multiple births Suhsteeee Ahusei Metereel egeJ Hypertension Ieterpersoeel safety Treesportetioe needs Housing Instability Food Ieseeurity Utility needs Ahuse4---- Enrollment ie CHIP uehore eoverege Prior poor pregeeeey outeomes._____________

1 Depression noted at anytime during the pregnancy or postpartum period (90 days postpartum) 2 History of use or current substance use 3 <21 or>35 4 Emotional, physical, or sexual 5 Fetal Death - Stillbirth after 20 weeks; Infant death -first year of life; Preterm birth - <37 weeks gestation; Low Birthweight - <2500 grams; Very Low Birthweight - <1500 grams; Other serious chronic conditions (ex: heart disease, renal disease, chronic medical illnesses, etc.); and, Maternal Death (death of a woman while

Effective Date: October 1, 2022 18 Approval Date: January 13, 2023

To he eligible fer the HSI, pregnant women and/or their infants in seleeted eounties must ha¥e at least one of the high risk faetors eited aho"ie and have an ineome no greater than the upper CmP limit (eurrently 312% FPL). HSI serviees will he offered whether or not the patient has health insuranee eoverage and regardless of the type of insuranee. Case management serviees fer individuals enrolled in Medieaid will he time limited until the implementation of the ease management serviees pra,•ided in the A,lahama Coordinated Health Network (ACHN) seheduled to begin Oetoher 1, 1019. Individuals with other insuranee that are provided ease management serviees will not he pFO"iided ease management serviees using HSI fends.

Patients will he enrolled in the HSI initiati"fe during pregnaney, during the post partum period, or by referral. Onee enrolled, HSI serviees will eontinue, as appropriate, fer one year post deli"fery with the eueptions noted in the paragraph aho"fe.

The HSI will he eoordinated by the Alabama Department of Puhlie Health and deli"fered through designated eounty health departments. Depending upon the needs of those partieipating in the initiative, serviees may he provided by puhlie health nurses, puhlie health soeial worl©rs, eommunity health workers, ete.

The proposed eounties fer initial implementation of the HSI inelude Montgomery, Maeon and Russell eounties. Serviees supported through this HSI will not supplant other federal, state or loeal funds alloeated fer similar serviees.

Outreaeh aetivities fer the RIM HSI inelude pro"iiding edueation and infermation to pertinent providers, hospitals and programs serving the target population residing in the eaunties in whieh the expansion is implemented.

In monitoring/evaluating the progress and sueeess of this program, the total number of women and ehildren served will he eaptured and reported to ALL Kids on an agreed upon sehedule hut no less than a quarterly basis. Traelang and reporting of "fisits and birth outeomes (birth weight, mortality within the first year of life and maternal health indiees) will also he ineluded in reports to ALL Kids.

The east of the HSI is budgeted to he $753,615 for FY 1019 (July Sept).

Case Management Costs: Initially, within the proposed three eounty area, approximately SOO women/families eould he served in FY 1019. The number of ease management hours per person/family is estimated to he 10 hours/quarter at an average east of $135/hour. This hourly rate would aeeount fer salary

pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes).

Effective Date: October 1, 2022 19 Approval Date: January 13, 2023

eost of those pFovidiBg/eooFdinating seFViees. ,"Additionally, it is estimated that staff will tFavel 25 miles peF home visit and theFe will be two home visits/patientlquarteF at the state mileage FeimbuFsement Fate of S0.545/mile.

Annual 1st QuarteF Case Management: EnFollees X ease management houFs S2,700,000 S(;75,000 X Sl35.00/houF TF&vel: # enFollees X miles/Found tFip X 2 tFips/quarteF X mileage S 54,500 S 13,(;25 FeimbuFsement Fate

Start Up/OutFeaeh Costs: As the HSI is being developed, eosts &Fe beiBg alloeated foF peFSonnel support to inelude up to two FTEs (one full time pFojeet manageF and otheF aneillaey support staff as needed). Additionally, eosts &Fe ineluded foF the development of mateFials to pFomote and edueate health eaFe pFovideFs and eommunity oFgani-zations thFoughout the implementation eounties about the initiative and to gaFneF support and partieipation of ageneieslpFovideFs. Edueation and awaFeness mateFials to outFeaeh to women will also be pFepaFed. E:Kpenses to eonduet (as well as attend) meetings, eonfeFenees andloF tFainings to shaFe infoFmation about the pFogFam and geneFate paFtieipation &Fe also ineluded as part of the startup and implementation eosts. ----------------------------+l•'HAnFHnFHUIH&Hl---+lst QuaFteF PeFsonnel Costs (Salary, FFiBge, IndiFeet eosts) S200,000 SS0,000 Edueational/tFainiBg mateFials S 10,000 Sl0,000 (pFovideFsloFgani-zations and partieipants) Costs foF meetings (tFansportatioe-/meetiBg fees)

GF&nd Total: S2,9(;9,SOO S7S3,fi2S (PeFsonnel, MateFials, Meeting eosts, Case Management)

HSI II: ALL Babies Postpartum Initiative: As permitted under section 2105(a)(l)(D)(ii) of the Social Security Act and federal regulations at 42 CFR 457.10, the State of Alabama is implementing a health services initiative (HSI) that will use CHIP funds, within the federal administrative expenditures cap allowed for states, to support the ALL Babies Postpartum Initiative. This HSI will not supplant or match CHIP Federal funds with other Federal funds, nor allow other Federal funds to supplant or match CHIP Federal funds. This HSI will assist in improving the health of children by ensuring their mothers have access to healthcare services during their postpartum period. The aim of this initiative is to provide full health insurance coverage during the postpartum period to enrollees who have been prenatally covered in the Reducing Infant Mortality Conception to Birth program known as ALL Babies. The length of the ALL Babies postpartum period is equivalent to Alabama Medicaid's current definition of the length of postpartum period "From delivery through the end of the month in which the 60th day postpartum falls, counting from the date the pregnancy ends either as a full term or as a miscarriage." ALL Babies participants will be enrolled automatically in the postpartum HSI

Effective Date: October 1, 2022 20 Approval Date: January 13, 2023

initiative. Metrics used to measure the impact of the state's HSI program on the health of low­ income children and their mothers will be included in the state's CHIP Annual Report.

Cost: The cost of the HSI is budgeted to be $360,000 for FY 2023. This figure is based on anticipated enrollment (870 enrollees) in 36 counties with an average enrollment of 2.5 months.

2.3-TC Tribal Consultation Requirements-(Sections 1902(a)(73) and 2107(e)(l)(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)(l)(C) of the Act was also amended to apply these requirements to the Children's Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

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

ALL Kids provides a certified letter to the federally recognized tribe in the state when considering amendments to the State Plan or other program changes requiring CMS approval. The tribe is given 30 days to respond. In the event of an emergency, ALL Kids will submit a faxed letter to the tribe and give 10 days for response.

Section 3. Methods of Delivery and Utilization Controls Check here if the State elects to use funds provided under Title XXI only to provide expandedD eligibility under the State's Medicaid plan, and continue on to Section 4. Guidance: In Section 3.1., discussion may include, but is not limited to: contracts with managed health care plans (including fully and partially capitated plans); contracts with indemnity health insurance plans; and other arrangements for health care delivery. The State should describe any variations based upon geography, as well as the State methods for establishing and defining the delivery systems.

Should the State choose to cover unborn children under the Title XXI State plan, the

Effective Date: October 1, 2022 21 Approval Date: January 13, 2023