Exhibit AC

Exhibit AC.doc

State Plan Under Title XIX of the Social Security Act (Base plan pages, Attachments, Supplements to Attachments)

Exhibit AC

OMB: 0938-0193

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Revision: HCFA‑PM‑87‑4 (BERC) OMB No.: 0938‑0193

MARCH 1987


State/Territory:


Citation 4.19(f) The Medicaid agency limits participation to

42 CFR 447.15 providers who meet the requirements of

1916A (d)(2) 42 CFR 447.15.

No provider participating under this plan may deny

services to any individual eligible under the plan on account of the individual's inability to pay a cost sharing amount imposed by the plan in accordance with 42 CFR 447.53. This service guarantee does not apply to an individual who is able to pay, nor does an individual's inability to pay eliminate his or her liability for the cost sharing change.




















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TN No.

Supersedes Approval Date Effective Date

TN No.

HCFA ID: 101OP/0012P


File Typeapplication/msword
AuthorCMS
Last Modified ByCMS
File Modified2008-10-24
File Created2008-05-06

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