State Plan List of Attachments

1.1-A Attorney General's Certification

1.1-B Waivers under the Intergovernmental Cooperation Act

1.2-A Organization and Function of State Agency

pg2 Org chart

1.2-B Organization and Function of Medical Assistance Unit

1.2-C Professional Medical and Supporting Staff

1.2-D Description of Staff Making Eligibility Determination

2.1-A DEFINITION OF HEALTH MAINTENANCE ORGANIZATION

2.2-A Groups Covered and Agencies Responsible for Eligibility Determinations

SPA SC 22-0004 CMS Approved MACPro template and cover letter

SPA SC 23-0002 CMS Approved MACPro template and cover letter

SPA SC 24-0027 CMS Approved MACPro template and cover letter

Eligibility Template

Supplement 1 - Reasonable Classifications of Individuals Under the Age of 21, 20, 19 and 18
Supplement 2 - Definitions of Blindness and Disability (Territories only)
Supplement 3 - Method of Determining Cost Effectiveness of Caring for Certain Disabled Children at Home

2.6-A Eligibility conditions and Requirements (States Only)

Supplement 1 - Income Eligibility Levels - Categorically Needy, Medically Needy and Qualified Medicare Beneficiaries
Supplement 2 - Resource Levels - Categorically Needy, Including Groups with Incomes Up to a Percentage of the Federal Poverty Level, Medically Needy, and other Optional Groups
Supplement 3 - Reasonable Limits on Amounts for Necessary Medical or Remedial Care Not Covered Under Medicaid
Supplement 4 - Section 1902(f) Methodologies for Treatment of Income that Differ from those of the SSI Program
Supplement 5 - Section 1902(f) Methodologies for Treatment of Resources that Differ from those of the SSI Program
Supplement 5a - Methodologies for Treatment of Resources for Individuals With Incomes Up to a Percentage of the Federal Poverty Level
Supplement 6 - Standards for Optional State Supplementary Payments
Supplement 7 - Income Levels for 1902(f) States - Categorically Needy Who Are Covered Under Requirements More Restrictive than SSI
Supplement 8 - Resource Standards for 1902(f) States - Categorically Needy
Supplement 8a - More Liberal Methods of Treating Income Under Section 1902(r)(2) of the Act
Supplement 8b - More Liberal Methods of Treating Resources Under Section 1902(r)(2) of the Act
Supplement 8c - State Long-Term Care Insurance Partnership
Supplement 9 - Transfer of Resources
Supplement 10 - Consideration of Medicaid Qualifying Trusts--Undue Hardship

2.6-A Eligibility Conditions and Requirements (Territories Only)

Supplement 1 - Income Eligibility levels - Categorically Needy, Medically Needy, and Qualified Medicare Beneficiaries
Supplement 2 - Reasonable Limits on Amounts for Necessary Medical or Remedial Care Not Covered Under Medicaid
Supplement 3 - Resource Levels for Optional Groups with Incomes Up to a Percentage of the Federal Poverty Level and Medically Needy
Supplement 4 - Consideration of Medicaid Qualifying Trusts-Undue Hardship
Supplement 5 - More Liberal Methods of Treating Income Under Section 1902(r)(2) of the Act
Supplement 6 - More Liberal Methods of Treating Resources Under Section 1902(r)(2) of the Act

3.1-A Amount, Duration, and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy

3.1-B Amount, Duration, and Scope of Services Provided Medically Needy Groups

3.1-C Standards and Methods of Assuring High Quality Care

3.1-D Methods of Providing Transportation

3.1-E Standards for the Coverage of Organ Transplant Procedures

3.1 F Managed Care

3.1 H HEALTH OPPORTUNITY ACCOUNTS DEMONSTRATION PROGRAM

Supplement 1

4.11-A Standards for Institutions

4.14-A Single Utilization Review Methods for Intermediate Care Facilities

4.14-B Multiple Utilization Review Methods for Intermediate Care Facilities

4.16-A Cooperative Arrangements with State Health and State Vocational Rehabilitation Agencies and with Title V Grantees

4.17-A Determining that an Institutionalized Individual Cannot Be Discharged and Returned Home

4.18-A Charges Imposed on Categorically Needy

4.18-B Medically Needy - Premium

4.18-C Charges Imposed on Medically Needy and Other Optional Groups

4.18-D Premiums Imposed on Low Income Pregnant Women and Infants

4.18-E Premiums Imposed on Qualified Disabled and Working Individuals

4.19-A Methods and Standards for Establishing Payment Rates - Inpatient Hospital Care

4.19-B METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - OTHER TYPES OF CARE

Supplement 1 - Methods and Standards for Establishing Payment Rates for Title XVIII Deductible/Coinsurance
Supplement 2 - Payment for Other Provider Preventable Conditions to include the three Never Events
Supplement 3 - Increased Primary Care Service Payment

4.19-C Payments for Reserved Beds

4.19-D Methods and Standards for Establishing Payment Rates - Skilled Nursing and Intermediate Care Facility Services

4.19 E- 4.43

4.19 E Timely-Claims Payment - Definition of Claim

4.20-A Conditions for Direct Payment for Physicians' and Dentists' Services

4.22-A Requirements for Third Party Liability -Identifying Liable Resources

4.22-B Requirements for Third Party Liability--Payment of Claims

4.22-C State Method on Cost Effectiveness of Employer Based Group Health Plans

4.30 Sanctions for MCOs and PCCMs

4.32-A Income And Eligibility Verification System Procedures Requests To Other State Agencies

4.33-A Method For Issuance Of Medicaid Eligibility Cards To Homeless Individuals

4.34-A Requirements For Advance Directives Under State Plans For Medical Assistance

4.35-A Criteria for the Application of Specified Remedies for Nursing Facilities

4.35-B Alternative Remedies to Specified Remedies for Nursing Facilities

4.35-C Enforcement of Compliance for Nursing Facilities

4.35-D Enforcement of Compliance for Nursing Facilities

4.35-E Enforcement of Compliance for Nursing Facilities

4.35-F Enforcement of Compliance for Nursing Facilities

4.35-G Enforcement of Compliance for Nursing Facilities

4.35-H Enforcement of Compliance for Nursing Facilities

4.38 Disclosure Of Additional Registry Information

4.38-A Collection Of Additional Registry Information

4.39 Definition Of Specialized Services

4.39-A Categorical Determinations

4.40-A Survey and Certification Education Program

4.40-B Process for the Investigation of Allegations of Resident Neglect and Abuse and Misappropriation of Resident Property

4.40-C Procedures for Scheduling and conduct of Standard Surveys

4.40-D Programs to Measure and Reduce Inconsistency

4.40-E Process for Investigations and complaints and Monitoring

4.42 Employee Education About False Claims Recoveries

4.43 Cooperation with Medicaid Integrity Program Efforts

7.2-A Methods of Administration - Civil Rights (Title VI)

7.7-A Vaccine and Vaccine Administration at Section 1905(a)(4)(E) of the Social Security Act

7.7-B COVID-19 Testing at section 1905(a)(4)(F) of the Social Security Act

7.7-C COVID-19 Treatment at section 1905(a)(4)(F) of the Social Security Act