Exhibit O

Revision: Supplement 1 to

ATTACHMENT 4.19‑B

Page 1

OMB No.:0938-

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:__________________

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

OTHER TYPES OF CARE

Payment of Medicare Part A and Part B Deductible/Coinsurance

Except for a nominal recipient co-payment (as specified in Attachment 4.18 of this State plan), if applicable, the Medicaid agency uses the general method for payment specified in the chart on page 2 of this supplement. Codes appearing in the chart have the meanings defined below:

1. SP: Payments are limited to State plan rates and payment methodologies.

For specific Medicare services which are not otherwise covered by this State plan, the Medicaid agency uses Medicare payment rates unless a special rate or method is set out on Page 3, section A of this supplement.

2. MR: Payments are up to the full amount of the Medicare rate.

3. NR: Payments are up to the amount of a special rate, or according to a special method, described on Page 3 in item __ of this attachment, for those groups and payments listed below and designated with the letters "NR".

4. Any exceptions to the general methods used for a particular group or payment are specified on Page 3, section B and Pages 3a & 3b of this supplement.

______________________________________________________________________________

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

Revision: Supplement 1 to

ATTACHMENT 4.19‑B

Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:__________________

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

OTHER TYPES OF CARE

Payment of Medicare Part A and Part B Deductible/Coinsurance

Group	Part A Deductible	Part A Coinsurance	Part B Deductible	Part B Coinsurance
QMB1
QMB Plus2
FBDE3

1. QMB: Qualified Medicare Beneficiary. A QMB is eligible for payment of all Medicare Part A and Part B deductibles and co-insurance, including those charged through a Medicare Part C plan. For QMB an entry must be made in each column.

2. QMB Plus: QMB Plus full Medicaid. A QMB Plus is eligible for payment of all Medicare Part A and Part B deductibles and co-insurance, including those charged through a Medicare Part C plan, as well as all benefits available to a fully eligible Medicaid recipient under the State plan. For QMB Plus an entry must be made in each column.

3. FBDE: Full Benefit Dual Eligible. A Medicare beneficiary who is eligible for Medicaid under the State plan but who does not meet income, resource or other criteria for eligibility as a QMB. States are liable only for services covered under the State plan and rendered by a provider enrolled in the State Medicaid program. Payment must be calculated based on the rate indicated above, less the Medicare payment liability and any other third party liability.

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

Revision: Supplement 1 to

ATTACHMENT 4.19‑B

Page 3

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:__________________

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

OTHER TYPES OF CARE

Payment of Medicare Part A and Part B Deductible/Coinsurance

Section A. If SP is entered on Page 2, specify the special rate or methodology used as the basis of payment for Medicare services which are not otherwise covered by this State plan, if the State is not using the Medicare rate for those services.

Section B. Specify any exceptions to the rates indicated on Page 2 for particular

groups or payment types.

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

Revision: Supplement 1 to

ATTACHMENT 4.19‑B

Page 3a

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: ________________

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

OTHER TYPES OF CARE

MEDICAID OBLIGATIONS FOR COST-SHARING IN MEDICARE PART C PLANS

____ The State opts to make capitated payments (per member per month-pmpm) for dual eligibles enrolled in Medicare Part C plans.

1. Part A and Part B Cost Sharing

A. Groups Capitated. The State makes pmpm payments for Medicare Part A and Part B cost sharing for the following individuals (as described on page 2 of this supplement) enrolled in a Medicare Part C plan:

____ QMB

____ QMB Plus

____ Full Benefit Dual Eligibles

2. Payment Methodology. Describe the payment methodology the State uses to determine pmpm payment amounts. This rate can be the actuarial equivalent of the Part A and Part B deductibles and coinsurance in fee-for-service Medicare. The baseline can also be built on pmpm payments to Medicaid Managed Care Organizations for a like population, and/or can be experience rated for factors such as age, disability, diagnosis, etc. Factors employed to arrive at the pmpm amounts and the method and timing of rate increases must be specified.

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

Revision: Supplement 1 to

ATTACHMENT 4.19‑B

Page 3b

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: ________________

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

OTHER TYPES OF CARE

MEDICAID OBLIGATIONS FOR COST-SHARING IN MEDICARE PART C PLANS

____________________________________________________________________________

2. Optional Supplemental Benefits or enrollment in a Special Needs Plan (SNP)

A. Groups enrolled. The State opts to make payments for optional supplemental benefits for the following individuals (as described on page 2 of this supplement) enrolled in a Medicare Part C plan or SNP:

____ QMB Plus

____ Full Benefit Dual Eligibles

B. Methodology. Describe the payment methodology used to determine the pmpm payment amount for cost sharing for optional supplemental benefits or enrollment in a SNP.

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____