Exhibit Y

Revision: HCFA‑PH‑87‑ 9 (BERC) OMB No.: 0938‑0193

AUGUST 1987

State/Territory:

Citation 4.19 (d)

42 CFR Subpart C (1) The Medicaid agency meets the requirements of

42 CFR Part 447, Subpart C, with respect to

payments for longterm care facility services and intermediate care facility for the mentally retarded services.

ATTACHMENT 4.19‑D describes the methods and standards used to determine rates for payment for longterm care services and intermediate care facility for the mentally retarded services.

(2) The Medicaid agency provides payment for routine longterm care facility services furnished by a swing‑bed hospital.

At a rate established by the State, which meets the requirements of 42 CFR Part 447, Subpart C, as applicable.

Not applicable. The agency does not provide payment for NF services to a swing‑bed hospital.

(3) The Medicaid agency provides payment for routine intermediate care facility for the mentally retarded services furnished by a swing‑bed hospital.

At a rate established by the State, which meets the requirements of 42 CFR Part 447, Subpart C, as applicable.

Not applicable. The agency does not provide payment for ICF services to a swing‑bed hospital.

(4) Section 4.19(d)(1) of this plan is not applicable with respect to intermediate care facility services; such services are not provided under this State plan.

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TN No.

Supersedes Approval Date Effective Date

TN No.

HCFA ID: 101OP/0012P