Form CMS-10398 (#21) CMS-10398 (#21) Threshold Methodology for Identification of Applicable F

OMB Control Number: 0938‐1148

Expiration date: 10/31/2014

Supplement 18 to Attachment 2.6A

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State Plan Under Title XIX of the Social Security Act

State: ----

THRESHOLD METHODOLOGY FOR IDENTIFICATION OF APPLICABLE FMAP RATES

The State will implement the threshold methodology to determine the appropriate FMAP rate for expenditures for individuals enrolled in the adult group described in 42 CFR 435.119 and receiving benefits in accordance with 42 CFR Part 440 Subpart C. The threshold methodology consists of two parts: an individual-based determination related to enrolled individuals, and as applicable, appropriate population-based adjustments.

Part 1 – Adult Group Individual Income-Based Determinations

For individuals eligible in the adult group, the state will make an individual income-based determination for purposes of the threshold methodology by comparing individual income to the relevant converted income eligibility standards in effect on December 1, 2009, and included in the MAGI Conversion Plan (Part 2) approved by CMS on ________________________ (insert date). Under the threshold methodology, the expenditures of individuals with incomes below the relevant converted income standards for the applicable subgroup will be provisionally considered as those for which the newly eligible FMAP is not available. The relevant MAGI-converted standards for each population group in the new adult group are described in Table 1.

Table 1 : Adult Group Eligibility Standards and Threshold Methodology Features

Covered Populations Within New Adult Group		Applicable Population Adjustment
Population Group	Relevant Population Group Threshold For each population group, indicate the lower of: The reference in the MAGI Conversion Plan (Part 2) to the relevant income standard and the appropriate cross-reference, or 133% FPL. If a population group was not covered as of 12/1/09, enter “Not covered”.	Resource Proxy	Enrollment Cap	Special Circumstances
		Enter “Y” (Yes), “N” (No), or “NA” in the appropriate column to indicate if the population adjustment will apply to each population group. Provide additional information in corresponding attachments.
A	B	C	D	E
Parents/Caretaker Relatives
Disabled Persons, non-institutionalized
Disabled Persons, institutionalized
Children Age 19, 20, or 21
Childless Adults

Part 2 – Population-based Adjustments to the Newly Eligible Population Based on Resource Test, Enrollment Cap or Special Circumstances

1. Optional Resource Criteria Proxy Adjustment (42 CFR 433.206(d))

1. ___ [STATE] applies a resource proxy adjustment to population group(s) subject to a resource test on December 1, 2009.

___ [STATE] does NOT apply a resource proxy adjustment (Skip items 2 through 3 and go to Section B)

Table 1 indicates the group or groups for which [STATE] applies a resource proxy adjustment to the expenditures applicable for individuals eligible and enrolled under 42 CFR 435.119. Resource proxies are only permitted for population groups that were subject to a resource proxy adjustment as of December 1, 2009.

The effective date(s) for application of the resource proxy adjustment is specified and described in Attachment B.

2. Data source used for resource proxy adjustments:

[STATE]:

___ Applies existing state data from periods before January 1, 2014.

___ Applies data obtained through a post-eligibility statistically valid sample of individuals.

Data used in resource proxy adjustments is described in Attachment B.

3. Resource Proxy Methodology: Attachment B describes the sampling approach or other methodology used for calculating the adjustment.

2. Enrollment Cap Adjustment (42 CFR 433.206(e))

1. ___ An enrollment cap adjustment is applied (complete items 2 through 4).

___ An enrollment cap adjustment is not applied (skip items 2 through 4 and go to Section C).

2. Attachment C describes any enrollment caps authorized in section 1115 demonstrations as of December 1, 2009 that are applicable to populations that [STATE] covers in the eligibility group described at 42 CFR 435.119 and received full benefits, benchmark benefits, or benchmark equivalent benefits as determined by CMS. The enrollment cap or caps are as specified in the applicable section 1115 demonstration special terms and conditions as confirmed by CMS, or in alternative authorized cap or caps as confirmed by CMS. Attach CMS correspondence confirming the applicable enrollment cap(s).

3. [STATE] applies a combined enrollment cap adjustment for purposes of claiming FMAP in the adult group:

___ Yes. The combined enrollment cap adjustment is described in Attachment C

___ No.

4. Enrollment Cap Methodology: Attachment C describes the methodology for calculating the enrollment cap adjustment, including the use of combined enrollment caps, if applicable.

3. Special Circumstances (42 CFR 433.206(g))

1. ___ [STATE] applies special circumstances adjustment(s) (complete item 2).

___ [STATE] does not apply a special circumstances adjustment (skip item 2 and go to Part 3).

2. Attachment D describes the special circumstances adjustment(s) that are applied, including the population groups to which the adjustments apply and the methodology for calculating the adjustments.

Part 3 – One-Time Transitions of Previously Covered Populations into the New Adult Group

1. Transitioning Previous Section 1115 and State Plan Populations to the New Adult Group

___ Individuals previously eligible for Medicaid coverage through a section 1115 demonstration program or a mandatory or optional state plan eligibility category will be transitioned to the new adult group described in 42 CFR 435.119 in accordance with a CMS-approved transition plan, included as Attachment E. For purposes of claiming federal funding at the appropriate FMAP for the populations transitioned to new adult group, the threshold methodology is applied pursuant to and as described in Attachment E, and where applicable, is subject to any special circumstances described in Attachment D.

___ [State] does not have any relevant populations requiring such transitions.

Part 4 - Applicability of Special FMAP Rates

1. Expansion State Designation

[STATE]:

___ Does NOT meet the definition of expansion state in 42 CFR 433.204(b). (Skip section B and go to Part 4)

___ Meets the definition of expansion state as defined in 42 CFR 433.204(b), determined in accordance with the CMS letter confirming expansion state status, dated __________________(insert date)

2. Qualification for Temporary 2.2 Percentage Point Increase in FMAP.

[STATE]:

___ Does NOT qualify for temporary 2.2 percentage point increase in FMAP under 42 CFR 433.10(c)(7).

___ Qualifies for temporary 2.2 percentage point increase in FMAP under 42 CFR 433.10(c)(7), determined in accordance with the CMS letter confirming eligibility for the temporary FMAP increase, dated _____________ (insert date). The [STATE] will not claim any federal funding for individuals determined eligible under 42 CFR 435.119 at the FMAP rate described in 42 CFR 433.10(c)(6).

Part 5 - State Attestations

The State attests to the following:

1. The application of the threshold methodology will not affect the timing or approval of any individual’s eligibility for Medicaid.

2. The application of the threshold methodology will not be biased in such a manner as to inappropriately establish the numbers of, or medical assistance expenditures for, individuals determined to be newly or not newly eligible.

ATTACHMENTS

Not all of the attachments indicated below will apply to all states; some attachments may describe methodologies for multiple population groups within the new adult group. Indicate those of the following attachments which are included with this SPA:

___ Attachment A – Conversion Plan Standards Referenced in Table 1

___ Attachment B – Resource Criteria Proxy Methodology

___ Attachment C – Enrollment Cap Methodology

___ Attachment D – Special Circumstances Adjustment Methodology

___ Attachment E – Transition Plans

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1148.  The time required to complete this information collection is estimated to average 4 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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TN – 14-XX Approval Date –xx-xx-xxx Effective Date – xx-xx-xxxx