CMS-10398 #51 1115(e) Extension State Certification

OMB No.: 0938-1148

CMS Form: CMS-10398 #51

[State] Application Certification Statement - Section 1115(e) Three Year Extension

This document, together with Appendices A through D, constitutes [insert state] application to the Centers for Medicare & Medicaid Services (CMS) to extend its demonstration entitled, [insert demo name and project no], without any programmatic changes pursuant to section 1115(e) of the Social Security Act. The state is requesting CMS’ approval for a 3-year extension of the demonstration subject to the same approved Special Terms and Conditions (STCs), waivers, and expenditure authorities currently in effect for the period [insert current demo period].

CMS’ expedited review and assessment of the state’s request to continue the demonstration without any substantive program changes is conditioned upon the state’s submission and CMS’ assessment of the below items that are necessary to ensure that the demonstration is operating in accordance with the objectives of title XIX and/or title XXI as originally approved. The state’s application will only be considered complete for purposes of initiating federal review and federal-level public notice when the state provides the information as requested in the below appendices.

• Appendix A: A historical narrative summary of the demonstration project, which includes the objectives set forth at the time the demonstration was approved, evidence of how these objectives have or have not been met, and the future goals of the program.

• Appendix B: Budget neutrality assessment, and projections for the projected 3-year extension period. The state will present an analysis of budget/allotment neutrality for the current demonstration approval period, including status of budget/allotment neutrality to date based on the most recent expenditure and member month data, and projected through the end of the current approval period. CMS will also review the state’s Medicaid and State Children’s Health Insurance Program Budget and Expenditure System (MBES/CBES) expenditure reports to ensure that the demonstration has not exceeded the Federal expenditure limits established for the demonstration. The state’s actual expenditures incurred over the period from initial approval through the current expiration date, together with the projected costs for the requested 3-year extension period, must comply with CMS budget/allotment neutrality requirements outlined in the STCs.

• Appendix C: Interim evaluation of the overall impact of the demonstration that includes evaluation activities and findings to date, in addition to plans for evaluation activities over the 3-year extension period. The interim evaluation should provide CMS with a clear analysis of the state’s achievement in obtaining the outcomes expected as a direct effect of the demonstration program. The state’s interim evaluation must meet all of the requirements outlined in the STCs.

• Appendix D: Summaries of External Quality Review Organization (EQRO) reports, managed care organization and state quality assurance monitoring, and any other documentation of the quality of and access to care provided under the demonstration.

• Appendix E: Documentation of the state’s compliance with the public notice process set forth in 42 CFR 431.408 and 431.420.

The state attests that it has abided by all provisions of the approved STCs and will continuously operate the demonstration in accordance with the requirements outlined in the STCs.

Signature:__________________________________ Date:______________________

[Governor]

CMS will notify the state no later than 15 days of submitting its application of whether we determine the state’s application meets the requirements for a streamlined federal review under section 1115(e). The state will have an opportunity to modify its application submission if CMS determines it does not meet the requirements of section 1115(e).

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 (CMS-10398 #51). The time required to complete this information collection is estimated to average 150 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.