Initial Application

Template I2 – Initial Application Data – Medicaid State Plan-Specific Submission Data

INTRODUCTION

In Template I2, States provide information about the Medicaid State Plan amendment they are submitting. This template applies only to Medicaid State plan amendments. This template must be completed before the plan amendment can be submitted for review and approval.

States should complete this template in accordance with the instructions in the Technical Guidance section below.

TECHNICAL GUIDANCE

Template I2 will display the following statement.

“This State Plan Amendment includes changes to the following sections.”

Three choices will then be displayed. The State should select as many of the three choices as apply in this package. For each choice selected, additional choices will be displayed.

• Administration

If this choice is selected, two additional choices will be displayed. The State should select as many of the two as apply. If this is the State’s first plan amendment under MACPro, the State must also complete Template A1 – Designation of Single State Agency and Template A2 – Organization and Statewide Operation regardless of whether either of the two choices below is selected. Validation: If this is the State’s first plan amendment under MACPro but the State has not completed Template A1 and Template A2, this package can be saved but it cannot be submitted until Templates A1 and A2 have been completed.

If this is not the State’s first MACPro plan amendment, Templates A1 and/or A2 will not be accessed unless this choice is selected.

• Designation of Single State Agency.

• Organization and Statewide Operation.

• Benefits

If this choice is selected one choice will be displayed.

• Alternative Benefits Plans (Benchmark Benefit Package or Benchmark-Equivalent Benefit Package).

If this choice is selected, two additional choices will be displayed. The State should select whichever of these two choices applies. Only one choice can be selected.

• Add an Alternative Benefit Plan

If this choice is selected, the State must also complete Template B2 – Eligibility.

• Amend existing Alternative Benefit Plan.

If this choice is selected, the State should go the Introduction for Template B1 – Benchmark Data.

If this choice is selected, a list of existing Alternative Benefit Plans will be displayed. The State should select as many from the list as apply to this package.

• The State may only submit one new Alternative Benefit Plan or amend one Alternative Benefit Plan in a single submission. If it has more than one new Alternative Benefit Plan or wishes to amend more than one Plan it must complete a separate submission for those amendments.

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