Form CMS-10398 #58 CMS-10398 #58 Implementation Plan Template

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
1. Title page for the state’s eligibility and coverage policies demonstration or eligibility and
coverage policies components of the broader demonstration
The state should complete this transmittal title page as a cover page when submitting its implementation
plan.
State

Enter state name.

Demonstration name

Enter full demonstration name as listed in the demonstration
approval letter.

Approval date

Enter approval date of the demonstration as listed in
the demonstration approval letter.

Approval period

Enter the entire approval period for the demonstration, including
a start date and an end date.

Implementation date

Enter implementation date(s) for the demonstration.

PRA Disclosure Statement - This information is being collected to assist the Centers for Medicare & Medicaid
Services in program monitoring of Medicaid Section 1115 Eligibility and Coverage Demonstrations. This mandatory
information collection (42 CFR § 431.428) will be used to support more efficient, timely and accurate review of
states’ eligibility and coverage 1115 demonstrations monitoring reports submissions to support consistency of
monitoring and evaluation of Medicaid Section 1115 Eligibility and Coverage Demonstrations, increase in reporting
accuracy, and reduce timeframes required for monitoring and evaluation. Under the Privacy Act of 1974 any
personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct
or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
Office of Management and Budget (OMB) control number. The OMB control number for this project is 0938-1148
(CMS-10398 # 58). Public burden for all of the collection of information requirements under this control number is
estimated to take about 20 hours per response. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard,
Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
2. Required implementation information, by eligibility and coverage policy
Answer the following questions about implementation of the state’s eligibility and coverage demonstration. States should respond to each prompt listed in the
tables. Note any actions that involve coordination or input from other organizations (government or non-government entities). Place “NA” in the summary cell
if a prompt does not pertain to the state’s demonstration. Answers are meant to provide details beyond the information provided in the state’s special terms and
conditions. Answers should be concise, but provide enough information to fully answer the question.
This template only includes CE policies.
Prompts
Summary
CE.Mod_1. Specify community engagement policies
Intent: To describe in more detail the CE policies outlined in the state’s STCs.
a) Full-time student status
1.1 Describe how the state will
define exempt populations,
Example: The state exempts full-time high school, college, and graduate students are exempt. The state defines full
including additional details about
time student status for college and graduate students as a minimum of at least 12 credit hours per semester (or the
how these exemptions are defined
and how long exemptions will last equivalent) at an accredited institution of higher education. The state will use the Board of Education’s definition
of full-time high school status, found in its reporting guidelines and procedures (link). College and graduate
if applicable:
a) Full-time student status
students must continue to meet these requirements to qualify for the CE exemption. High school students will
remain exempt even if they do not meet these requirements during their summer break.
b) Medical frailty and other
medical conditions
b) Medical frailty and other medical conditions
c) Pregnancy
d) Acute medical condition
e) Former foster care youth
c) Pregnancy
d) Acute medical condition
e) Former foster care youth

3

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
f) Beneficiaries in substance use
disorder treatment
g) Beneficiaries who are
homeless
h) Beneficiaries who were
incarcerated within the last six
months
i) Beneficiaries receiving
unemployment benefits
j) Enrollment in the state’s
Medicaid employer premium
assistance program
k) Caregiver of a dependent
l) Beneficiaries exempt from
TANF/SNAP requirements
m) Other (by specific exempt
status)

Summary
f) Beneficiaries in substance use disorder treatment
g) Beneficiaries who are homeless
h) Beneficiaries who were incarcerated within the last six months
i) Beneficiaries receiving unemployment benefits
j) Enrollment in the state’s Medicaid employer premium assistance program
k) Caregiver of a dependent
l) Beneficiaries exempt from TANF/SNAP requirements
m) Other

1.2 Provide additional details
about qualifying community
engagement activities and the
number of required CE hours.
a) Hour requirements
b) Extra hours policy

a) Hour requirements
Example: The state requires 80 hours per month of qualifying CE
b) Extra hours policy
activities.

4

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
c) Grace period
d) Reporting frequency and hours
measurement

Summary
c) Grace period

1.3 Provide additional details on
how the state will:
a) Define the circumstances that
give rise to good cause
b) Review additional
circumstances that fall outside
the defined list of
circumstances
c) Determine how long
individual good cause
circumstances will apply

a) Define the circumstances that give rise to good cause

d) Reporting frequency and hours measurement

Example: The state considers the following circumstances as meriting good cause: 1) the beneficiary has a disability
as defined by the ADA, section 504 of the Rehabilitation Act, or section 1557 of the Patient Protection and
Affordable Care Act and was unable to meet the requirement for reasons related to that disability; 2) the beneficiary
has an immediate family member in the home with a disability under federal disability rights laws and was unable to
meet the requirement for reasons related to the disability of that family member; 3) the beneficiary or an immediate
family member who was living in the home with the beneficiary experiences a hospitalization or serious illness.
b) Review additional circumstances

c) How long individual good cause circumstances apply

1.4 Provide additional details on
how the state will define the
following compliance actions:
a) Opportunity to cure/grace
periods
b) Suspension

a) Opportunity to cure/grace periods
Example: The state will allow beneficiaries an opportunity to cure non-compliance. In the month immediately
following the month in which a beneficiary has failed to meet the community engagement hours requirement, the
beneficiary may cure non-compliance by completing 80 hours of community engagement activities in that
calendar month. The opportunity to cure may be used once per calendar year.
b) Suspension

5

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
c) Termination
d) Non-eligibility period
e) Other compliance actions

Summary
c) Termination
d) Non-eligibility period
e) Other compliance actions

CE.Mod_2. Establish beneficiary supports and modifications
Intent: To describe how states will provide supports to beneficiaries to ensure that they are able to meet CE requirements.
Specific supports
2.1 Describe planned
Summary
transportation supports and how
the state will connect beneficiaries Example: The state Medicaid agency has developed a partnership with the state department of transportation to
with those supports.
ensure that beneficiaries are aware of the state’s free public transportation program for low-income state
residents. CE beneficiaries have been mailed notices about this program. All beneficiaries subject to CE
requirements qualify for free or significantly reduced access to public transportation. Call center staff have also
been trained to direct beneficiaries to these transportation supports.
Summary
2.2 Describe planned child care
supports and how the state will
connect beneficiaries to those
supports.
2.3 Describe planned language
Summary
support services for non–Englishspeaking beneficiaries and how the
state will connect beneficiaries
with those supports.

6

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
2.4 Describe if the state will
Summary
provide or connect beneficiaries to
any other supports, including
Example: Managed care organizations in the state will provide CE supports, such as job and skills training,
assistance from other agencies and GED programs, and referrals to education and volunteering, that serve beneficiaries subject to the CE
requirement.
entities complementing Medicaid
efforts.
Ensure that CE activities are available and accessible
2.5 Describe the state’s strategy
Summary
for ensuring training opportunities,
including job search training, onthe-job training, and job skills
training, are available and
accessible to beneficiaries.
2.6 Describe public programs that
Summary
the state Medicaid agency will
partner with to leverage existing
employment and training supports.
Describe how the arrangements
will work, and indicate if these
supports will be available to all
demonstration beneficiaries
subject to CE requirements or if
other qualifying restrictions will
apply. Describe how the state will
fund such employment and
training supports.
2.7 Describe how the state will
Summary
modify community engagement
requirements in areas with few CE
opportunities and how often these
adjustments will be reviewed.
7

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
Reasonable modifications for individuals with disabilities (in compliance with all applicable federal laws, including the Americans with Disabilities
Act, Section 504 of the Rehabilitation Act, Section 1557 of the Affordable Care Act, Title VI of the Civil Rights Act, and the Age Discrimination Act)
2.8 Describe the planned
Summary
modifications to community
engagement requirements
available to beneficiaries with
disabilities.
2.9 Describe the state’s process for Summary
assessing and providing
modifications to community
engagement requirements
available to beneficiaries with
disabilities.
2.10 Describe how the state will
Summary
connect beneficiaries with
disabilities to needed supports and
services.
2.11 Describe any additional steps Summary
the state will take to ensure
compliance with all applicable
federal laws related to people with
disabilities.
CE.Mod_3. Establish procedures for enrollment, verification, and reporting
Intent: To describe modifications to enrollment processes as well as verification and reporting of activities and exemptions.
Modifications to application, enrollment, and renewal procedures
3.1 Describe any planned changes Summary
to the state’s application(s) and
application/enrollment processes
Example: The state intends to revise its single streamlined application to include questions about adults’ current
to identify beneficiaries subject to work hours, Those not already working more than a specified hours/week that would exempt them from reporting
will be provided a separate form post-enrollment to determine whether they meet other exemptions.
or exempt from CE requirements.
8

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
3.2 Describe any planned changes Summary
to the state’s renewal processes for
the CE demonstration population.
For example, will the state update
any pre-populated renewal forms
to capture information on CE
compliance or exemptions?
3.3 Describe any other planned
Summary
modifications to the state’s
eligibility determination and
Example: The state is planning to revise its application and enrollment processes to incorporate community
enrollment processes and
engagement eligibility requirements. All applications for beneficiaries who may be subject to CE will be funneled to
operations as a result of
a new unit for processing. These eligibility staff will be specifically trained on CE enrollment policies.
implementation of CE
requirements. For example, will
applications for beneficiaries who
may be subject to CE be funneled
to a specific unit for processing?
Describe any impact that this may
have on processing time for
applications.
Procedures for beneficiaries to report CE activities
3.4 Describe how beneficiaries
Summary
will report compliance with CE
requirements. For example, what
Example: Beneficiaries must report monthly hours online, in a state portal, by phone, or in person at a local office
are the modalities to report hours
by the 5th day of the following month following compliance.
and how frequently are
beneficiaries required to report?

9

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
3.5 In states that allow online
Summary
reporting, describe any reporting
modifications available to
beneficiaries without Internet
access.
Procedures for CE entities to report CE activities
Summary
3.6 Describe if the state plans to
develop capacities so that
employers, volunteer supervisors,
schools, and other representatives
can report CE activities on behalf
of beneficiaries. Describe the
procedures for CE entities to report
CE activities.
Procedures for beneficiaries to report or file for an exemption
3.7 Describe the procedures for
Summary
beneficiaries to report standard
exemptions as defined in section
1.1 (e.g., pregnancy, full time
student status, homelessness) and
what documentation is required, if
any. Note whether specific
exemptions must be reported
differently.
3.8 Describe the procedures for
Summary
beneficiaries to file for good cause
as defined in section 1.3 and what
documentation is required, if any.

10

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
State verification of CE activities and exemptions
3.9 Describe how the state will
Summary
verify beneficiaries’ compliance
with CE requirements. For
Example: The state will accept beneficiaries’ monthly attestation of reported hours unless the agency has
information to indicate a discrepancy. On a quarterly basis, the agency will identify a random sample of 10 percent
example, note whether the state
of beneficiaries subject to CE requirements and attempt to verify reported hours against state wage data, SNAP,
will accept self-attestation of
TANF, and other data sources.
beneficiary-reported hours or
verify hours through use of data
from other sources. Specify how
periodic audits will be conducted,
if applicable.
Summary
3.10 Describe how the state will
verify exemptions as defined in
section 1.1, if applicable.
3.11 Describe if and how the state Summary
will use data from SNAP and
TANF. Describe the process for
identifying beneficiaries enrolled
in SNAP/TANF and exempt from
or meeting CE requirements for
those programs. Describe how the
state will ensure that those
beneficiaries are also counted as
meeting or exempt from Medicaid
CE requirements, as applicable.

11

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
3.12 Describe if and how the state Summary
will use additional data sources or
leverage other entities to verify
compliance with or identify
potential exemptions from CE
requirements (e.g., state wage data,
unemployment, managed care
organizations [MCO]).
CE.Mod_4. Operationalize strategies for noncompliance
Intent: To describe how states will implement the policies for beneficiaries who do not comply with CE requirements.
Strategies for beneficiaries at risk of noncompliance
4.1 Describe how the state will
identify beneficiaries at risk of
noncompliance.
4.2 Describe what strategies the
state will use to assist beneficiaries
at risk of noncompliance in
meeting the requirements.
4.3 Describe how the state will
implement the following
compliance actions, including
what processes the state will
implement to identify and track
beneficiaries in these statuses:
a) Suspension
b) Termination
c) Non-eligibility period

Summary
Example: The state has developed new functionality in its systems to automatically flag beneficiaries who are at
risk of becoming non-compliant in the next month unless they report CE hours or apply for an exemption.
Summary

a) Suspension
b) Termination
c) Non-eligibility period

12

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
d) Other compliance actions (e.g., d) Other compliance actions
grace periods/ opportunity to
cure)
4.4 Provide details on the state’s
Summary
plan, if applicable, to provide
advance notice to beneficiaries at
risk of suspension or disenrollment
for noncompliance. Include when
the state will notify beneficiaries
and how many notices or other
communications (e.g., calls) each
beneficiary will receive.
4.5 Describe the state’s process for Summary
benefit reactivation (from
suspension) and/or re-enrollment
(from termination) once
community engagement
requirements are met.
4.6 Describe the process by which Summary
a beneficiary who is about to be
suspended or disenrolled will be
screened for other Medicaid
eligibility groups or exemptions
(e.g., by sending form to
potentially eligible beneficiaries to
capture additional information).

13

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
Summary
4.7 Describe any
differences/modifications from the
current renewal process, including
changes for beneficiaries in
suspension status due to
noncompliance with CE
requirements.
Stopping payments to managed care
4.8 Describe procedures to stop
Summary
capitation payment to MCOs when
a beneficiary’s eligibility is
suspended or terminated due to
failure to comply with CE
requirements.
4.9 Describe if and how
Summary
beneficiaries will be made aware
of ways to access primary and
preventive care at low or no cost
after disenrollment or during a
suspension.
Re-enrollment after disenrollment for noncompliance
4.10 Describe what beneficiaries
Summary
will need to do to re-enroll
following disenrollment or
suspension for failure to comply
with CE requirements.

14

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
4.11 Describe how the state will
process new applications for
individuals who were disenrolled
for non-compliance if it differs
from the state’s standard
application processes.
4.12 Describe how the state will
handle applications for individuals
who reapply for coverage but are
still in suspended status or noneligibility period, if applicable. For
example, will the state process
those applications with a
prospective eligibility date or will
the state deny those applications
until individuals are eligible.
Appeals processes
4.13 Describe any modifications to
the appeals processes for
beneficiaries enrolled in the CE
demonstration, including appeals
for:
a) Suspensions or disenrollment
for noncompliance;
b) Denials of exemption or good
cause requests
Describe what happens to the
beneficiary while the case is
pending or in the appeals/fair
hearing process, if it differs from
the current process.

Summary
Summary

Summary

Summary

15

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
CE.Mod_5. Develop comprehensive communications strategy
Intent: To describe how the state will communicate CE policies and procedures (as necessary) to internal and external stakeholders (beneficiaries,
partners, staff/other internal entities).
Beneficiary communication
5.1 Provide details on the state’s
Summary
plan to communicate to current
beneficiaries and new
Example:
applicants/beneficiaries about
The state will provide beneficiaries with official notices about when CE requirements will commence, the number of
required hours per week, how to report hours, specific activities that may be used to satisfy the requirements, and
general CE policies, including
when community engagement
supports that are available to assist beneficiaries in meeting the requirements. These will be provided twice, 30 days
requirements will commence, the
and 15 days prior to the CE requirements going into effect. The Medicaid agency is also working with local
community partners to host events in the community to provide information about general CE polices and answer
number of required community
engagement hours and frequency
questions. The Medicaid agency plans to hold at least one event in every county. Material about how to report
hours has been distributed to local libraries and other community partners that have computers that beneficiaries
of completion, how to report
can use to enter their hours into the online portal.
compliance and on what
frequency, specific activities that
may be used to satisfy community
engagement requirements, and
information about resources that
will facilitate compliance such as
the availability of transportation
and child care. Include details such
as how often the state plans to
communicate with beneficiaries
and through what modes of
communication, including what
information will be distributed
using formal notices.

16

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
Summary
5.2 Provide details on the state’s
plan to communicate to
beneficiaries about exempt
populations and good cause
circumstances. Include details
such as how often the state plans to
communicate with beneficiaries
and through what modes of
communication, including what
information will be distributed
using formal notices.
Summary
5.3 Provide details on the state’s
plan to communicate to
beneficiaries about suspension or
disenrollment for
noncompliance. Include details
such as how often the state plans to
communicate with beneficiaries,
through what modes of
communication, including what
information will be distributed
using formal notices.

17

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
5.4 Provide details on the state’s
Summary
plan to communicate to
beneficiaries about reactivation
following suspension or re-entry
after disenrollment for
noncompliance. Include details
such as how often the state plans to
communicate with beneficiaries,
through what modes of
communication, including what
information will be distributed
using formal notices.
5.5 Describe the state’s plan for
Summary
communicating to beneficiaries
about changes in requirements. For
example, how will beneficiaries be
notified of differences in the
requirements they need to meet if
they transition off SNAP/TANF
but remain subject to community
engagement requirements.
5.6 Describe any plans to use CE
Summary
partners, such as qualified health
plans, managed care organizations,
providers, or community
organizations to communicate to
beneficiaries and conduct
outreach, such as delivering
education and ensuring compliance
with CE requirements.
18

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
5.7 Describe how the state will
ensure that materials or
communications are accessible to
beneficiaries with limited English
proficiency, low literacy, in rural
areas, and other diverse groups.
Describe the process for testing
beneficiary notices for reading
level and comprehension.

Summary
Summary

5.8 Describe the state’s plans for
translating beneficiary notices into
languages other than English, and
note what other languages will be
available.

Summary

5.9 Describe the state’s plan to
communicate modifications of
community engagement
requirements to beneficiaries with
disabilities.

Summary

Partner communications
5.10 Describe the state’s plan to
conduct outreach to partner
organizations.
5.11 Describe how the state plans
to keep partner organizations
informed and engaged, including
all forms of communication that
the state plans will use to engage
partner organizations.

Summary

Summary

19

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Staff/internal communications

Summary

5.12 Describe internal staff
trainings that the state is planning
to conduct, such as trainings for
call center representatives.

Summary

5.13 Describe any internal
materials that the state is planning
to develop for staff, such as
manuals or reference guides.

Summary

20

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
Summary
CE.Mod_6. Establish continuous monitoring
Intent: To describe the state’s process for conducting process and quality improvement for the CE program.
6.1 Describe any analyses that the
Summary
state is planning to conduct to
inform its monitoring beyond the
Example: The state is planning to conduct beneficiary phone surveys and track beneficiaries who are not reporting
CMS required quarterly and
hours due to technical difficulties. If the state identifies a substantial number of beneficiaries are not reporting
hours due to technical difficulties, the state will consider providing additional notices to beneficiaries and/or
annual monitoring reports.
training CE partner entities who help beneficiaries enter hours into the state’s online portal.
Describe the state’s process for
determining whether changes are
needed for the following:
a) Beneficiaries exempt from
community engagement
requirements
b) Qualifying community
engagement activities and
required hours
c) Reporting frequency and hours
measurement
d) Situations that give rise to
good cause
e) Compliance actions
f) Other policy changes

21

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
6.2 Describe any actions needed to
ensure that the state can capture
and report required quarterly and
annual monitoring metrics.
Describe any necessary structural
or process changes (i.e. data
sharing systems/agreements with
MCOs) that the state must make in
order to capture and report
required quarterly and annual
monitoring metrics. IT changes
need only be discussed in section
7.

Summary
Summary

6.3 Describe how the state will
assess the availability of accessible
transportation supports by region
and how the state will address gaps
in supports. Note the frequency
with which the state will assess the
availability of transit and
transportation supports.

Summary

6.4 Describe how the state will
assess the availability of child care
supports by region and how it will
address gaps in supports. Note the
frequency with which the state will
assess the availability of child care
supports.

Summary

22

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
6.5 Describe how the state will
assess the availability of language
access services by region and
address gaps in supports. Note the
frequency with which the state will
assess the availability of language
access services.

Summary
Summary

6.6 Describe how the state will
assess the availability of other
supports, including assistance from
other agencies and entities
complementing Medicaid efforts,
by region and address gaps in
supports. Note the frequency with
which the state will assess the
availability of other supports.

Summary

6.7 Describe how the state will
assess whether qualifying
community engagement activities
are available during a range of
times, through a variety of means,
and throughout the year. Describe
any additional analysis that the
state is planning to conduct to
verify the available community
engagement opportunities.

Summary

23

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
6.8 Describe how the state will
identify geographic areas with
high unemployment and limited
economic and/or educational
opportunities. Describe how the
state will adjust community
engagement requirements in areas
with few CE opportunities and
how often those adjustments will
be reviewed.
6.9 Describe how the state will
assess reasonable modifications
and the availability of supports for
beneficiaries with disabilities by
region. Describe how the state will
address gaps in supports. Note the
frequency with which the state will
assess reasonable modifications
and the availability of supports.

Summary
Summary

Summary

CE.Mod_7. Develop, modify, and maintain systems
Intent: To describe any system changes needed to implement CE policies and meet reporting requirements.
7.1 Describe whether the state is
Summary of planned changes or enhancements
planning to enhance its eligibility
and enrollment systems to
Example: The state plans to enhance current system capabilities to identify and tag beneficiaries in the system
who must comply with and those who are already exempt from CE requirements. The state will establish data
determine eligibility for the CE
sharing agreements with SNAP/TANF and automate the system to flag exempt SNAP/TANF beneficiaries.
demonstration population.
7.2 Describe whether the state is
Summary of planned changes or enhancements
planning to develop or enhance
systems capacities so that
beneficiaries can report CE hours.
24

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
7.3 Describe whether the state is
planning to develop or enhance
systems capacities so that CE
entities, such as employers,
volunteer supervisors, schools, and
other institutions, can
automatically report CE activities
completed by beneficiaries.
7.4 Describe whether the state is
planning to develop or enhance
systems capacities to integrate data
from other public programs, such
as SNAP and TANF.
7.5 Describe any systems
modifications that the state is
planning to operationalize the
suspension of benefits and/or
termination of eligibility.
Describe any changes to the
determination of eligibility,
including changes to the MMIS
eligibility module to show
someone is in a suspended status.

Summary
Summary of planned changes or enhancements

Summary of planned changes or enhancements

Summary of planned changes or enhancements

25

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Prompts
7.6 Describe any systems
modifications that the state is
planning to operationalize benefit
reactivation and/or re-enrollment
once community engagement
requirements are met. Describe
what changes states with noneligibility periods will implement
to prevent enrollment during these
periods.
7.7 Describe any other significant
systems modifications the state is
planning to operationalize
community engagement
requirements.

Summary
Summary of planned changes or enhancements

Summary of planned changes or enhancements

26

Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan
[State] [Demonstration Name]
[Demonstration Approval Date]
Submitted on [Insert Date]
Section 3: Relevant documents
Please provide any additional documentation or information that the state deems relevant to successful
execution of the implementation plan. This information is not meant as a substitute for the information
provided in response to the prompts outlined in Section 2. Instead, material submitted as attachments
should support those responses.

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