CENTERS FOR MEDICARE AND MEDICAID SERVICES SPECIAL TERMS AND CONDITIONS

For a complete copy of CMS Terms and Conditions see: http://www.conduitforaction.org/arkspecialtermsandconditions/

(Note: some words may have been mistyped in this document through conversion from pdf to text format to shorten)

NUMBER:     ll-W-00287/6

 TITLE:   Arkansas Health Care Independence Program (Private Option)

AWARDEE:  Arkansas Department of Human Services

I. PREFACE

The following are the Special Terms and Conditions (STCs) for the Arkansas Health Care Independence Program (Private Option) section 1115(a) Medicaid demonstration (hereinafter demonstration) to enable Arkansas (State) to operate this demonstration. The Centers for Medicare & Medicaid Services (CMS) has granted waivers of requirements under section 1902(a) of the Social Security Act (Act), and expenditure authorities authorizing federal matching of demonstration costs not otherwise matchable, which are separately enumerated. These STCs set forth in detail the nature, character, and extent of federal involvement in the demonstration and the State’s obligations to CMS during the life of the demonstration. The STCs are effective on the date of the signed approval. Enrollment activities for the new adult population will begin on October  1, 2013 for the Private Option qualified health plan (QHP) with eligibility effective January  1, 2014.  The demonstration will be statewide and is approved through  December  31, 2016.

The STCs have been arranged into the following subject areas:

 

  1. Preface
  2. Program Description And Objectives
  3. General Program Requirements
    1. Populations  Affected
    2. Private Option Premium Assistance Enrollment
      1. Premium Assistance Delivery System
        1. Benefits
        2. Cost Sharing
          1. Appeals
          2. General Reporting Requirements
            1. General Financial Requirements
              1. Monitoring Budget Neutrality
            2. Evaluation
              1. Monitoring
                1. Health Information Technology and Premium Assistance
        3. T-MSIS

 

  1. PROGRAM DESCRIPTION AND OBJECTIVES

 

Under the Private Option demonstration, the State will provide premium assistance, to support the purchase by beneficiaries eligible under the new adult group under the state plan of coverage from QHPs offered in the individual market through the Marketplace.  In Arkansas, individuals eligible for coverage under the new adult group are both (1) childless adults ages 19 through 64 with incomes at or below 133 percent of the federal poverty limit (FPL) or (2) parents and other caretakers between the ages of 19 through 64 with incomes between 17 percent and 133 percent of the FPL (collectively Private Option beneficiaries).  Arkansas expects approximately 200,000 beneficiaries to be enrolled into the Marketplace through this demonstration program.

 

Private Option beneficiaries will receive the State plan Alternative Benefit Plan (ABP) primarily through a QHP that they select and will have cost sharing obligations consistent with the State plan.

 

With this demonstration Arkansas proposes to further the objectives of Title XIX by:

  • Promoting continuity of coverage for individuals,
    • Improving access to providers,
      • Smoothing the “seams” across the continuum of coverage, and
      • Furthering quality improvement and delivery system reform initiatives.

 

Arkansas proposes that the demonstration will provide integrated coverage for low-income Arkansans, leveraging the efficiencies of the private market to improve continuity, access, and quality for Private Option beneficiaries.  The state proposes that the demonstration will also drive structural health care system reform and more competitive premium pricing for all individuals purchasing coverage through the Marketplace by doubling the size of the population enrolling in QHPs offered through the Marketplace.

 

The state proposes to demonstrate following key features:

 

Continuity of coverage and care -For households with members eligible for coverage under Title XIX and Marketplace coverage as well as those who have income fluctuations that cause their eligibility to change year-to-year, or multiple times throughout the year, the demonstration will create continuity of health plans available for selection as well as provider networks. Households may stay enrolled in the same plan regardless of whether their coverage is subsidized through Medicaid, or Advanced Payment Tax Credits/Cost Sharing Reductions (APTC/CSRs).

 

Support equalization of provider reimbursement and improve provider access – The demonstration will support equalization of provider reimbursement across payers, toward the end of expanding provider access and eliminating the need for providers to cross-subsidize. Arkansas Medicaid provides rates of reimbursement lower than Medicare or commercial payers, causing some providers to forego participation in the program and others to “cross subsidize” their Medicaid patients by charging more to private insurers.

 

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demonstration, the governor or chief executive officer of the State must submit to CMS either a demonstration extension request or a transition and phase-out plan consistent with the requirements of STC 9.

 

  1. Compliance with Transparency Requirements at 42 CFR §431.412.

 

  1. As part  of  the demonstration  extension  requests  the State must  provide  documentation  of compliance  with the transparency  requirements  42 CFR  §431.412 a:tJ.d the public notice and tribal  consultation  requirements  outlined  in STC  15.

 

  1. Demonstration Phase Out.  The State may only suspend or terminate this demonstration in whole, or in part, consistent with the following requirements.

 

  1. Notification of Suspension or Termination: The State must promptly notify CMS in writing of the reason(s) for the suspension or termination, together with the effective date and a transition and phase-out plan.  The State must submit its notification letter and a draft plan to CMS no less than six (6) months before the effective date of the demonstration’s suspension or termination.  Prior to submitting the draft plan to CMS,  the State must publish on its website the draft transition and phase-out plan for a 30-day public comment period. In addition, the State must conduct tribal consultation in

accordance with its approved tribal consultation State Plan Amendment. Once the 30-day public comment period has ended, the State must provide a summary of each public comment received the State’s response to the comment and how the State incorporated the received comment into the revised plan.

 

  1. The State must obtain CMS approval of the transition and phase-out plan prior to the implementation of the phase-out activities. Implementation of activities must be no sooner than 14 days after CMS approval of the plan.

 

  1. Transition  and Phase-out Plan Requirements: The State must include, at a minimum, in its plan the process by which it will notify affected beneficiaries, the content of said notices (including information on the beneficiary’s appeal rights), the process by which the State will conduct administrative reviews of Medicaid eligibility prior to the termination of the program for the affected beneficiaries, and ensure ongoing coverage for those beneficiaries  determined eligible, as well as any community outreach activities including community resources that are available.
  2. Phase-out Procedures: The State must comply with all notice requirements found in 42 CFR §431.206, §431.210, and §431.213. In addition, the State must assure all appeal and

 

  • hearing rights afforded to demonstration participants as outlined in 42 CFR §431.220 and

§431.221. If a demonstration participant requests a hearing before the date of action, the State must maintain benefits as required in 42 CFR §431.230. In addition, the State must conduct administrative renewals for all affected beneficiaries in order to determine if they qualify for Medicaid eligibility under a different eligibility category.  42 CFR Section 435.916.

  1. Exemption from Public Notice Procedures 42.CFR Section 431.416(g).  CMS may expedite the federal and State public notice requirements in the event it determines that the objectives of title XIX and XXI would be served or under circumstances described in 42 CFR Section 431.416(g).

f.    Federal Financial Participation (FFP): If the project is terminated or any relevant waivers suspended by the State, FFP shall be limited to normal closeout costs associated with terminating the demonstration including services and administrative costs of disenrolling participants.

 

10.  Post Award Forum.  Within six months of the demonstration’s implementation,  and annually thereafter, the State will afford the public with an opportunity to provide meaningful comment on the progress of the demonstration.  At least 30 days prior to the date of the planned public forum, the state must publish the date, time and location of the forum in a prominent location on its website.  The state can either use its Medical Care Advisory Committee, or another meeting that is open to the public and where an interested party can learn about the progress of the demonstration to meet the requirements of this STC.  The state must include a summary of the comments in the quarterly report as specified in STC 46 associated with the quarter in which the forum was held.  The State must also include the summary in its annual report as required in STC 48.

 

11.  Federal Financial Participation (FFP).  If the project is terminated or any relevant waivers suspended by the state, FFP shall be limited to normal closeout costs associated with terminating the demonstration including services and administrative costs of disenrolling enrollees.

 

  1. Expiring Demonstration Authority. For demonstration authority that expires prior to the demonstration’s expiration date, the state must submit a transition plan to CMS no later than six months prior to the applicable demonstration authority’s’ expiration date, consistent with the following requirements:

 

  1. Expiration Requirements.  The state must include, at a minimum, in its demonstration expiration plan the process by which it will notify affected beneficiaries, the content of said notices (including information on the beneficiary’s appeal rights), the process by which the State will conduct administrative reviews of Medicaid eligibility for the affected beneficiaries, and ensure ongoing coverage for eligible individuals, as well as any community outreach activities.

 

(Pages 7-17 omitted)

  1. Administrative Costs.  Administrative  costs will not be included in the budget neutrality limit, but the State must separately track and report additional administrative costs that are directly attributable to the demonstration, using Forms CMS-64.10 Waiver and/or 64.10P Waiver, with waiver name Local Administration Costs (“ADM”).

 

  1. Claiming Period.  All claims for expenditures subject to the budget neutrality limit (including any cost settlements) must be made within 2 years after the calendar quarter in which the State made the expenditures.  Furthermore, all claims for services during the demonstration period (including any cost settlements) must be made within 2 years after the conclusion or termination of the demonstration.  During the latter 2-year period, the State must continue to identify separately net expenditures related to dates of service during the operation of the section 1115 demonstration on the Form CMS-64 and Form CMS-21 in order to properly account for these expenditures in determining budget neutrality.

 

  1. Reporting Member Months. The following describes the reporting of member months for demonstration  populations:

 

  1. For the purpose of calculating the budget neutrality expenditure cap and for other purposes, the State must provide to CMS, as part of the quarterly report required under STC 46, the actual number of eligible member months for the demonstration populations defined in STC 17. The State must submit a statement accompanying the quarterly report, which certifies the accuracy of this information.

 

To permit full recognition of “in-process” eligibility, reported counts of member months may be subject to revisions after the end of each quarter. Member month counts may be revised retrospectively as needed.

 

  1. The term “eligible member months” refers to the number of months in which persons are eligible to receive services.  For example, a person who is eligible for three months contributes three eligible member months to the total.  Two individuals who are eligible for two months each contribute two eligible member months to the total, for a total of four eligible member months.

 

  1. Standard Medicaid  Funding Process.   The standard Medicaid  funding process  must be used during the demonstration.  The State must estimate matchable demonstration

expenditures (total computable and federal share) subject to the budget neutrality expenditure

cap and separately report these expenditures by quarter for each federal fiscal year on the Form CMS-37 for both the Medical Assistance Payments (MAP) and State and Local Administration Costs (ADM).  CMS will make federal funds available based upon the State’s estimate, as approved by CMS.  Within 30 days after the end of each quarter, the State must submit the Form CMS-64 quarterly Medicaid expenditure report, showing Medicaid expenditures made in the quarter just ended.  The CMS will reconcile expenditures reported on the Form CMS-64 quarterly with federal funding previously made available to the State, and include the reconciling adjustment in the finalization of the grant award to the State.