Exhibit A1

Revision:

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

MEDICAL ASSISTANCE PROGRAM

Territory: __________________

SECTION 2 – COVERAGE AND ELIGIBILITY

______________________________________________________________________________

Citation(s)

______________________________________________________________________________

2.1 Application, Determination of Eligibility and Furnishing Medicaid

42 CFR 436.10 (a) The Medicaid agency meets all requirements of 42 CFR Part 436,

and Subpart J Subpart J for processing applications, determining eligibility, and furnishing Medicaid.

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

Revision:

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

MEDICAL ASSISTANCE PROGRAM

Territory: __________________

SECTION 2 – COVERAGE AND ELIGIBILITY

______________________________________________________________________________

Citation(s)

______________________________________________________________________________

2.1 Application, Determination of Eligibility and Furnishing Medicaid

(Continued)

1902(a)(34) of (b) (1) Except as provided in item 2.1(b)(2) below, or otherwise

the Act specified in Attachment 2.2-A or 2.6-A, individuals are entitled to Medicaid services under the plan during the three months preceding the month of application, if they were, or on application would have been, eligible. The effective date of prospective and retroactive eligibility is specified in ATTACHMENT 2.2-A or 2.6A.

1902(e)(8) and (2) For individuals who are eligible for Medicare cost-sharing

1905(a) of the Act expenses as Qualified Medicare Beneficiaries under section 1902(a)(10)(E)(i) of the Act, coverage is available for services furnished after the end of the month in which the individual is first determined to be a Qualified Medicare Beneficiary. ATTACHMENT 2.6-A specifies the requirements for determination of eligibility for this group.

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

Revision:

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

MEDICAL ASSISTANCE PROGRAM

Territory: __________________

SECTION 2 – COVERAGE AND ELIGIBILITY

______________________________________________________________________________

Citation(s)

______________________________________________________________________________

2.1 Application, Determination of Eligibility and Furnishing Medicaid

(Continued)

42 CFR 438.6 (c) The Medicaid agency elects to enter into a risk contract that complies with 42 CFR 438.6 and is procured through an open, competitive procurement process that is consistent with 45 CFR Part 74. The risk contract is with (check all that apply):

An HMO qualified under title XIII of the Public Health Service Act.

A MCO that meets the definition of 1903(m) of the Act and 42 CFR 438.2.

A PIHP that meets the definition of 1903(m) of the Act and 42 CFR 438.2.

A PAHP that meets the definition of 1903(m) of the Act and 42 CFR 438.2.

Not applicable.

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

Revision:

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

MEDICAL ASSISTANCE PROGRAM

Territory: __________________

SECTION 2 – COVERAGE AND ELIGIBILITY

______________________________________________________________________________

Citation(s)

______________________________________________________________________________

1. Application, Determination of Eligibility and Furnishing Medicaid

(Continued)

1902(a)(55) of (d) The Medicaid agency has procedures to take applications, assist

the Act applicants, and perform initial processing of applications from those poverty-related low income pregnant women, infants, and children under age 19, described in section 1902(a)(10)(A)(i)(IV), 1902(a)(10)(A)(i)(VI), 1902(a)(10)(A)(i)(VII), and 1902(a)(10)(A)(ii)(IX) of the Act at locations other than those used for the receipt and processing of applications for the title IV-A program including Federally-qualified health centers and disproportionate share hospitals. Such application forms do not include the application form for cash assistance under title IV-A except as permitted by CMS instructions.

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

Revision:

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

MEDICAL ASSISTANCE PROGRAM

Territory: __________________

SECTION 2 – COVERAGE AND ELIGIBILITY

______________________________________________________________________________

Citation(s)

______________________________________________________________________________

2.2 Coverage and Conditions of Eligibility

42 CFR 436.10 Medicaid is available to the groups specified in ATTACHMENT 2.2-A.

Mandatory categorically needy and other required special groups only.

Mandatory categorically needy, other required special groups, and the medically needy, but no other optional groups.

Mandatory categorically needy, other required special groups, and specified optional groups.

Mandatory categorically needy, other required special groups, specified optional groups, and the medically needy.

The conditions of eligibility that must be met are specified in ATTACHMENT 2.6-A.

All applicable requirements of 42 CFR Part 436 and sections 1902(a)(10)(A)(i), 1902(a)(10)(A)(ii), 1902(a)(10)(C), 1902(a)(10)(E), 1902(a)(10)(F), 1920, 1920A and 1920B of the Act are met.

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

Revision:

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

MEDICAL ASSISTANCE PROGRAM

Territory: __________________

SECTION 2 – COVERAGE AND ELIGIBILITY

______________________________________________________________________________

Citation(s)

______________________________________________________________________________

2.3 Residence

42 CFR 436.10, Medicaid is furnished to eligible individuals who are residents of the

436.403 and 1902(b) State under 42 CFR 436.403, regardless of whether or not the

of the Act, P.L. 99- individuals maintain the residence permanently or maintain it at a

272 (Section 9529) fixed address.

and P.L. 99-509

(Section 9405)

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

Revision:

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

MEDICAL ASSISTANCE PROGRAM

Territory: __________________

SECTION 2 – COVERAGE AND ELIGIBILITY

______________________________________________________________________________

Citation(s)

______________________________________________________________________________

2.4 Blindness

42 CFR 436.530(b) All of the requirements of 42 CFR 436.530 and 42 CFR 436.531 are

42 CFR 436.531 met. The definition of blindness in terms of ophthalmic measurement used in this plan is specified in Supplement 2 to ATTACHMENT 2.2-A.

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

Revision:

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

MEDICAL ASSISTANCE PROGRAM

Territory: __________________

SECTION 2 – COVERAGE AND ELIGIBILITY

______________________________________________________________________________

Citation(s)

______________________________________________________________________________

2.5 Disability

42 CFR 436.540(b) All of the requirements of 42 CFR 436.540 and 436.541 are met. The

and 42 CFR 436.541 definition of disability that is used in this plan is specified in Supplement 2 to ATTACHMENT 2.2-A.

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

Revision:

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

MEDICAL ASSISTANCE PROGRAM

Territory: __________________

SECTION 2 – COVERAGE AND ELIGIBILITY

______________________________________________________________________________

Citation(s)

______________________________________________________________________________

2.6 Financial Eligibility

42 CFR 436.10 and (a) The financial eligibility conditions for Medicaid-only eligibility

Subparts G and H groups and for persons deemed to be cash assistance recipients

1902(a)(10)(A)(i)(III), are described in ATTACHMENT 2.6-A.

1902(a)(10)(A)(i)(IV),

1902(a)(10)(A)(i)(V),

1902(a)(10)(A)(i)(VI),

1902(a)(10)(A)(i)(VII),

1902(a)(10)(A)(ii),

1902(a)(10)(C),

1902(a)(10)(E),

1902(a)(10)(F),

1902(r)(2), 1920,

1920A and 1920B

of the Act

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

Revision:

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

MEDICAL ASSISTANCE PROGRAM

Territory: __________________

SECTION 2 – COVERAGE AND ELIGIBILITY

______________________________________________________________________________

Citation(s)

______________________________________________________________________________

2.7 Medicaid Furnished Out of State

42 CFR 431.52 and Medicaid is furnished under the conditions specified in 42 CFR

1902(b) of the Act, 431.52 to an eligible individual who is a resident of the State while

P.L. 99-272 (Section the individual is in another State, to the same extent that Medicaid is

9529) furnished to residents in the State.

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____