Form CMS-10434 #1 CMS-10434 #1 Initial Application Combined

Template A2 – Organization and Administration
Statute: Section 1902(a)(4)
Regulation: 42 CFR 431.11
INTRODUCTION
In this template, the State provides a description of the organization and functions of the
Medicaid agency, the medical assistance unit and the staff making eligibility decisions, if
other than the Medicaid agency.
BACKGROUND
The designated State agency should have in place, an organizational structure and
staffing sufficient to support the administration and operation of the State’s Medicaid
program.
States are required to have a medical assistance unit within the Medicaid agency, staffed
with a program director and other appropriate personnel who participate in the
development, analysis, and evaluation of the Medicaid program.
TECHNICAL GUIDANCE
Template A2 consists of three sections
•
•
•

Medicaid Agency Organization
Medical Assistance Unit
Eligibility Staffing

Medicaid Agency Organization
In this section, States must provide a description of the organization and functions of the
Medicaid agency in the text box provided.
The State must then attach an organizational chart of the Medicaid agency via the upload
function.
Medical Assistance Unit
In this section, the State must identify the entity designated as the medical assistance unit
and provide a description of the organization and functions of the medical assistance unit
in the text boxes provided.
The State must then attach an organizational chart of the Medicaid agency’s medical
assistance unit via the upload function

Next the State must enter the kinds and numbers of professional medical personnel and
supporting staff, in the Medicaid Agency, used in the administration of the plan and their
responsibilities, in the text boxes provided.
Eligibility Staffing
This section of the template displays only for States which indicated in template A1
(Designation and Authority) that eligibility decisions are made by other than the
Medicaid Agency or the Medicaid agency plus other agencies.
The system will display each entity checked in template A1 and for each agency, the
State must enter a description of the staff designated by the agency and the functions they
perform in carrying out their responsibilities, in the text boxes provided.
Note for CMS: Please provide guidance as to what may or may not be acceptable
responses. For example, is there a minimum requirement as to credentials of staff making
eligibility decisions, such as having a bachelor’s degree?

Template CA1 – Designation and Authority
Statute: Section 1902(a)(5)
Regulation: 42 CFR 431.10
INTRODUCTION
Template CA2 must be completed by all States
In this template, the State names the single State agency authorized to administer and
submit the State Plan for the State’s Medicaid program, and agrees to administer the
program in accordance with the provisions of the State Plan, the requirements of title XI
and XIX (as appropriate) of the Social Security Act, and all applicable Federal
regulations and other official issuances.
BACKGROUND
States must designate a single State agency to administer or supervise the administration
of the State’s Medicaid plan and provide certification by the State Attorney General,
citing the legal authority for the single State agency to administer or supervise the
administration of the Medicaid plan and to make rules and regulations that it follows in
administering the plan or that are binding upon local agencies that administer the plan.
For families and children, Medicaid eligibility determinations may be made by the
State Medicaid agency; and/or the State agency under Title IV-A (in the 50 states or
the District of Columbia) or under Title I or XVI (in Guam, Puerto Rico, or the Virgin
Islands); and/or a government-operated Exchange established under sections
1311(b)(1) or 1321(c)(1) of the Affordable Care Act.
For the aged, blind, and disabled, Medicaid eligibility determinations must be made by
the State Medicaid agency; or the State agency under Title IV-A (in the 50 states or
the District of Columbia) or under Title I or XVI (in Guam, Puerto Rico, or the Virgin
Islands); or by the agency or agencies administering the supplemental security
income program.

A State must implement and administer its Medicaid program in accordance with the
approved State plan, any approved State plan amendments, the requirements of title XI
and title XIX (as appropriate), and all applicable Federal regulations. CMS monitors the
operation of the approved State plan and plan amendments to ensure compliance.
TECHNICAL GUIDANCE
Following the introductory statement, this template contains the following sections:
•
•

Agency Type
Single State Agency Responsibility

•
•

Administration of the Plan
Responsibility for Eligibility Determinations

Agency Type
The name of the Medicaid Agency is displayed at the top of this section and the State
must then select the agency type that corresponds to the Agency named above. Only one
option may be selected from the list provided.
If ‘Other’ is selected, the State must then enter the agency type in the text box provided.
Note for CMS: Need guidance as to types of State agencies which may be or not be
acceptable.
This is followed by a statement that the named agency (the Medicaid agency name will
be prefilled here) is the single State agency designated to administer or supervise the
administration of Medicaid program under title XIX of the Social Security Act.
Single State Agency Responsibility
The state must select one of the two following options as to the administrative
responsibility of the Medicaid agency:
•

Administering the plan

•

Supervising the administration of the plan by local political subdivisions

If ‘Administering the plan’ is selected, the State must then enter the statutory citation for
the legal authority under which the agency administers the plan, in the text box provided.
If ‘Supervising the administration of the plan by local political subdivisions’ is selected,
the State must then enter the statutory citations for both the legal authority under which
the agency administers the plan on a statewide basis and under which the Medicaid
agency has legal authority to make rules and regulations that are binding on the political
subdivisions administrating the plan, in the text boxes provided.
This is followed by the State being asked to assure that ‘the certification signed by the
State Attorney General identifying the single State agency and citing the legal authority
under which it administers or supervises administration of the program has been
provided’.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.

The State must then attach the certification via the Upload function.
Administration of the Plan
This section begins with a statement that ‘The State Plan may be administered solely by
the Single State Agency, or some portions may be administered by other agencies’.
This is followed by a Y/N question for the State to indicate if the single State agency
administers the entire State Plan under title XIX.
If the response is no, i.e., no other agency or organization administers any portion of it,
the State selects one or both of the following options:
•

The agency that administers or supervises the administration of the plan under
Title X of the Act as of January 1, 1965, has been separately designated to
administer or supervise the administration of that portion of this plan related to
blind individuals.

•

Waivers of the single State agency requirement have been granted under authority
of the Intergovernmental Cooperation Act of 1968.

If the State selects ‘The agency that administers or supervises the administration of the
plan under Title X….’, the following statement displays: The following designated state
agency has a separate plan covering that portion of the State Plan under title XIX for
which it is responsible. The State must then enter in the name and type of agency in the
text boxes provided.
If the State selects ‘Waivers of the single State agency requirement….’, the State must
then indicate by selecting Y/N as to whether the waivers are still in effect.
If the response is yes, i.e. the waivers are still in effect, then the State must
provide the following information in the text boxes provided:
•
•
•
•
•

Name of waiver;
Name of state agency to which responsibilities have been delegated;
Organizational arrangement authorized;
Nature and extent of the responsibility for program administration delegated;
Resources and/or services of the agency to be utilized in the administration of
the plan

Note for CMS: Please provide guidance as to what may or may not be acceptable
responses for ‘Nature and extent of the responsibility for program administration
delegated’. That is, is there a level of delegation that the State cannot exceed?
Responsibility for Eligibility Determinations

This section has two parts:
•

Entity or entities that have responsibility for all determinations of eligibility for
families, adults, and for individuals under 21.
Here States must select one, two or all three options displayed.

•

Entity that has responsibility for all determinations of eligibility for the aged,
blind, and disabled
In this part, States must select only one of the three options listed. If the State
selects ‘The Federal agency administering the SSI program’, the State must then
‘Indicate which agency determines eligibility for any groups whose eligibility is
not determined by the Federal agency’ by selecting only one of the two options
listed (Medicaid or title IV-A agency).

Template A3– Assurances
Statute:
Regulation:
INTRODUCTION
In template A3, the State provides assurances as to various administrative functions,
performed by the State Medicaid agency, and compliance with certain regulatory
requirements.
BACKGROUND
States may indicate that they comply with certain statutory or regulatory provisions by
providing assurances to that effect in their State plans. Assurances required in this section
include:
•

That the State Plan is in operation on a statewide basis, in accordance with all the
requirements of 42 CFR 435.510;

•

That all provisions of this plan are administered by the Medicaid agency except
for those functions for which final authority has been granted to a Professional
Standards Review Organization under title XI of the Act;

•

That all requirements of 42 CFR 431.10 are met;

•

That there is a Medical Care Advisory Committee to the agency director on health
and medical services established in accordance with meeting all the requirements
of 42 CFR §431.12; and

•

That there is a written agreement between the Medicaid agency and the Federal or
other State or local agencies that determine eligibility for Medicaid in compliance
with 42 CFR 431.10(d)

•

That State or local agencies or offices that perform services for the Medicaid
agency must not have the authority to change or disapprove any administrative
decision of that agency, or otherwise substitute their judgment for that of the
Medicaid agency with respect to the application of policies, rules, and regulations
issued by the Medicaid agency.

TECHNICAL GUIDANCE
In template A3 the State is being asked to provide the assurances listed above.

The State provides these affirmative assurances by checking the boxes next to the
assurance statements. If the State does not check this box, the system will not accept this
template for review and approval.

Template I1 – Initial Application Template – State Information
INTRODUCTION
In Template I1, States provide information about the amendment they are submitting.
This template applies to Medicaid State plan amendments and amendments to a State’s
CHIP program. This template must be completed for each separate package the State is
submitting.
States should complete this template in accordance with the instructions in the Technical
Guidance section below.
TECHNICAL GUIDANCE
Template I1 first asks for:
•

The name of the State or Territory.

•

The name of the Medicaid or CHIP agency.

The name of the State or Territory is automatically populated from the User Profile,
which must be completed before Template I1 can be submitted for review and approval.
Validation: If the State has not completed the User Profile, Template I1 can be saved but
it cannot be submitted until the User Profile has been completed.
The name of the Medicaid or CHIP agency is automatically populated from Template P1
– State Profile, which must be completed before Template I1 can be submitted for
review and approval. Validation: If the State has not completed Template P1, Template
I1 can be saved but cannot be submitted until Template P1 has been completed.
Template I1 next asks the State to identify the type of package it is submitting. The
following four choices are displayed. The State should select whichever of the four
choices applies. The State can select only one of the four choices shown.
•

Intent to Modify Package (Concept Paper).
This is a paper describing in general terms what the State is considering in the
way of modifying its currently approved State plan. Often known as a Concept
Paper, this submission is intended to be a basis for discussion between the State
and CMS. Since this is an informal submission, the 90-day clock for review and
action by CMS does not apply.
If this choice is selected, the State should also complete Template Z1 – Intent to
Modify.

•

Draft Submission Package.
This is normally a completed plan amendment package, but instead of submitting
it formally for review and approval, the State is submitting the package to CMS
for informal review and technical assistance. This is often done to help speed the
approval process by ensuring that all potential technical and other issues have
been addressed before the package is formally submitted to CMS for approval.
Since this is an informal submission, the 90-day clock for review and action by
CMS does not apply.
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Template I1 – Initial Application Template – State Information
•

Official Submission Package.
This is a formal submission to CMS for review and approval of the Medicaid or
CHIP plan amendment. Because this is a formal submission, the 90-day clock for
review and action by CMS applies.

If either “Draft Submission Package” or “Official Submission Package” was selected
under “SUBMISSION TYPE” above, the State will be asked for information about the
authority under which the State’s package is being submitted. The following two choices
will be displayed. The State should select whichever of the two choices applies. Only
one choice can be selected.
•

Medicaid State Plan Amendment.

•

CHIP State Plan Amendment.

When the “SUBMISSION TYPE” and “SUBMISSION AUTHORITY” sections have
been completed, the information provided by the State in those sections will be
displayed. The State will then be asked to provide the following information about the
Authorized Submitter and Key Contacts for the package.
Authorized Submitter Information
•

Name.

•

Title.

•

Telephone Number.

•

Email Address.

The above information is automatically populated from Template P1 – State Profile,
which must be completed before Template I1 can be submitted for review and approval.
Validation: If the State has not completed Template P1, Template I1 can be saved but
cannot be submitted until Template P1 has been completed.
Key Contacts Information
•

Name.

•

Title.

•

Telephone Number.

•

Email Address.

The above information is automatically populated from Template P1 – State Profile,
which must be completed before Template I1 can be submitted for review and approval.
Validation: If the State has not completed Template P1, Template I1 can be saved but
cannot be submitted until Template P1 has been completed.
If the State has more than one Key Contact for this package, the user can call up
additional spaces in which the required information can be entered. For the each Key
Contact entered, the following three choices will be displayed.
•

This is the primary contact for this submission package.
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Template I1 – Initial Application Template – State Information
•

This is the secondary contact for this submission package.

•

This is the tertiary contact for this submission package.

For each Key Contact, the appropriate choice should be selected. Once a choice is
selected, only the remaining choices will be displayed for selection for other Key
Contacts.
If either “Medicaid State Plan Amendment” or “CHIP State Plan Amendment” was
selected in the “SUBMISSION AUTHORITY” section, and the “SUBMISSION TYPE”
selected is either “Draft Submission Package” or “Official Submission Package”, the
following will be displayed:
“State Plan Transition to MACPro”
“This submission reflects transitioning the current State Plan to the new State Plan
without changes.”
The State should enter either “Y” (Yes) or “N” (No) in the space provided.
If the State enters “Y” (Yes), a field titled “Baseline Effective Date” will be displayed on
each screen of the State Plan Amendment material included in this submission package.
In each place where “Baseline Effective Date” is displayed, the State must enter the most
recent approval date for this material as shown in the paper version of the State’s plan.
If the State enters “N” (No), a request for the following additional information will be
displayed.
•

Proposed Effective Date. This should be entered as MM/DD/YYYY in the space
provided.

Regardless of the selection made under “SUBMISSION AUTHORITY”, if the
“SUBMISSION TYPE” selected is either “Draft Submission Package” or “Official
Submission Package”, the following will be displayed:
•

EXECUTIVE SUMMARY
In the space provided, the State should provide a brief, summary description of
the package being submitted, including the goals and objectives of the
submission.
Review Criteria

The description must be sufficiently clear, detailed and complete to permit the reviewer
to understand the purpose of the package being submitted.
•

DISASTER-RELATED SUBMISSION
The following statement will be displayed:
“This submission is related to a disaster.”
The State should enter either “Y” (Yes) or “N” (No) in the space provided. If the
“Y” (Yes) is entered, the State should provide a brief, summary description of the
disaster or emergency for which the package is being submitted.

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Template I1 – Initial Application Template – State Information
Review Criteria
The description must be sufficiently clear, detailed and complete to permit the reviewer
to understand the purpose of the package being submitted.
If either “Medicaid State Plan Amendment” or “CHIP State Plan Amendment” was
selected in the “SUBMISSION AUTHORITY” section, and the “SUBMISSION TYPE”
selected is either “Draft Submission Package” or “Official Submission Package”, the
following information will be requested:
•

FEDERAL BUDGET IMPACT
o Federal Fiscal Year. This should be entered as YYYY in the space provided.
o Amount. This should be entered as a dollar amount in the space provided.
The information requested is for the first year of the package. The same
information is requested for the second year of the package, and should be entered
in the same manner as the first year.

•

FEDERAL STATUTE/REGULATION CITATION
In the space provided, the State should enter the federal statute and/or regulatory
citations under which the package is being submitted.

If “Official Submission Package” was selected under “SUBMISSION TYPE”, and if
either “Medicaid State Plan Amendment” or “CHIP State Plan Amendment” was selected
in the “SUBMISSION AUTHORITY”, the following will be displayed.
•

GOVERNOR’S OFFICE REVIEW
Under this heading four choices will be displayed. The State should select
whichever of the four choices applies. Only one of the four choices can be
selected.
o No comment.
o Comments received.

If this choice is selected, the State should enter a summary of the comments
received in the space provided.
Review Criteria
The summary must be sufficiently clear, detailed and complete to permit the reviewer to
understand the comments made by the governor’s office.
o No response within 45 days.
o Other.
If “Other” is selected, the State should enter a description of “Other” in the
space provided.
Review Criteria
The description must be sufficiently clear, detailed and complete to permit the reviewer
to understand the selection made.

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Template I1 – Initial Application Template – State Information
For all Submission Types and Authorities, the following will be displayed.
•

AUTHORIZED SUBMITTER’S SIGNATURE
“ I hereby certify that I am authorized to submit this package on behalf of the
Medicaid Agency.”
The Authorized Submitter’s electronic signature must be entered in the space
provided. Validations: If the Authorized Submitter’s electronic signature is not
entered in the space provided, this package can be saved but cannot be submitted
until the signature is entered in the space provided.

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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.
o Designation of Single State Agency.
o Organization and Statewide Operation.



Benefits
If this choice is selected one choice will be displayed.
o Alternative Benefits Plans (Benchmark Benefit Package or BenchmarkEquivalent 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
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Template I2 – Initial Application Data – Medicaid State Plan-Specific Submission
Data





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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Template I4 – Children's Health Insurance Program State Plan - Amendment
Submission
Statute:
Regulation: 42 CFR 457.60
INTRODUCTION
Template I4 is used by all States with CHIP programs (separate CHIP and Medicaid
Expansion) to indicate the sections of the State Plan it wishes to update or amend.
BACKGROUND
Upon submission of an initial State Plan, all States will be required to complete all the
templates in the State Plan applicable to the type of CHIP program (separate CHIP,
Medicaid expansion or both) for which the State is seeking plan approval. The applicable
templates will automatically display for the State to complete.
Regulation allows States to amend its approved CHIP State plan in whole or in part at
any time through the submission of an amendment to CMS.
Additionally, a State must amend its State plan whenever necessary to reflect:
(a) Changes in Federal law, regulations, policy interpretations, or court decisions
that affect provisions in the approved State plan;
(b) Changes in State law, organization, policy, or operation of the program that
affect the following program elements described in the State plan:
(1) Eligibility standards, enrollment caps, and disenrollment policies as
described in 42 CFR 457.305.
(2) Procedures to prevent substitution of private coverage as described in
42 CFR 457.805, and in 42 CFR 457.810 for premium assistance
programs.
(3) The type of health benefits coverage offered, consistent with the
options described in 42 CFR 457.410.
(4) Addition or deletion of specific categories of benefits covered under
the State plan.
(5) Basic delivery system approach as described in 42 CFR 457.490.
(6) Cost-sharing as described in 42 CFR 457.505.

(7) Screen and enroll procedures, and other Medicaid coordination
procedures as described in 42 CFR 457.350.
(8) Review procedures as described in 42 CFR 457.1120.
(9) Other comparable required program elements.
(c) Changes in the source of the State share of funding, except for changes in the
type of non-health care related revenues used to generate general revenue.
TECHNICAL GUIDANCE
Currently, this template consists of the following sections:
•
•

Administration
Eligibility

The State would first select the section or sections (from the two options listed above)
impacted by the State Plan amendment.
Administration
Select the topic from the list of four options displayed. For each topic selected, the
system will display the corresponding screen(s) for the State to update.
Eligibility
There are three sub-sections to Eligibility:
•
•
•

Covered Groups
Non-Financial Requirements
General Eligibility

Each sub-section includes a list of topics from which the State can select. For each topic
selected, the system will display the corresponding screen(s) for the State to update.
Note: With few exceptions, listed below, the screen(s) displayed will be the screen
corresponding to the topic named in the option that was selected (i.e. if Completion of or
change to Targeted Low-Income Children is selected, the system will display the screen
for Targeted Low-Income Children).
Exceptions:
For ‘Addition of a covered group’ the Separate CHIP Options screen will be displayed
first, followed by the Completion of Covered Groups screen.

For ‘Deletion of a Covered Group’, the Separate CHIP Options screen will display for the
State to de-select the covered group it wants to delete.
Note: States with only a Medicaid Expansion Program can only access the options under
Administration and CS3 (Medicaid Expansion) and CS14 (Children Ineligible for
Medicaid Due to Loss of Income Disregards) under the Eligibility section.

Template I5 – Initial Application Data – Public Comment
INTRODUCTION
In Template I5, States provide information about public comments pertaining to the
package they are submitting. This template applies to Medicaid State plan amendments
and amendments to a State’s CHIP program. This template must be completed for each
separate package the State is submitting.
States should complete this template in accordance with the instructions in the Technical
Guidance section below.
TECHNICAL GUIDANCE
Template I5 will display the following statement.
“Indicate whether public comment was solicited with respect to this submission.”
Three choices will then be displayed. The State should select whichever of the choices
applies to this package. Only one choice can be selected.
•

Public notice was not required and comment was not solicited.

•

Public notice was not required, but comment was solicited.

• Public notice was required, and comment was solicited.
If either “Public notice was not required, but comment was solicited” or
“Public notice was required, and comment was solicited” is selected the following
statement will be displayed.
“Indicate how public comment was solicited.”
Six additional choices will then be displayed. The State should select as many of these
choices as apply to the package being submitted.
Review Criteria
If either of the Alternative Benefits Plan options is selected in the “Benefits” section of
Template I2 – Initial Application - Medicaid State Plan, the dates associated with the
public notice or notices must be entered, and all dates must be prior to the date of
submission of the official submission package for this amendment.
•

Newspaper Announcement.
If this choice is selected, the State must provide the following information in the
spaces provided.
o Name of Paper.
o Date of Publication. This should be entered as MM/DD/YYYY.
o Locations covered.
If more than one newspaper carried the announcement, the user can call up
additional spaces in which to enter the required information.

•

Publication in the State’s administrative record, in accordance with the
administrative procedures requirements.

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Template I5 – Initial Application Data – Public Comment
If this choice is selected, the State must enter the date of publication in the space
provided. This should be entered as MM/DD/YYYY.
•

Email to Electronic Mailing List or Similar Mechanism.
If this choice is selected, the State must enter the date of email or other electronic
notification in the space provided. This should be entered as MM/DD/YYYY.
The State must also enter a description of the mailing list in the space provided.
This description must include the particular parties and organizations included in
the list. If the notification was by a mechanism other than email, the State must
describe the specific mechanism or mechanisms used.

Review Criteria
The description must be sufficiently clear, detailed and complete to permit the
reviewer to understand and identify the parties and organizations to which the emails
and/or other methods were directed, as well as understand any mechanism other than
email that was used.
•

Website Notice.
If this choice is selected, the following statement will be displayed.
“Select the type of website:”
Additional choices will then be displayed. The State should select as many of
these choices as apply in this package.
o Website of the State Medicaid Agency or Responsible Agency.

o Website for State Regulations.
o Other.
If “Other” is selected, the State must enter the type of website in the space
provided. If there is more than one type of website under “Other”, the user can
call up additional spaces in which the required information can be entered.
Review Criteria
The description of the type of website must be sufficiently clear, detailed and complete
to permit the reviewer to understand and identify the website.
For each type of website selected above, the State must enter in the spaces
provided:
o Date of Posting. This should be entered as MM/DD/YYYY.
o Website URL.
•

Public Hearing or Meeting.
If this choice is selected, the State must provide the following additional
information.
o Date of Meeting. This should be entered as MM/DD/YYYY.
o Time of meeting. This should be entered as AM or PM hours and
minutes.
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Template I5 – Initial Application Data – Public Comment
o Location of meeting. This should be entered as a street address or other
readily understandable means of identification.
o Telephone Capability Used.
o Web Conferencing Capability Used.
The State must also provide information about the type of public forum used. The
State should select as many of the following choices as apply.
o The Medical Care Advisory Committee that operates in accordance with
42 CFR 431.12.
o A commission or other similar process, where meetings are open to
members of the public.
If this choice is selected, the State must enter the name of the commission
or process in the space provided.
o A State legislative process, which would afford an interested party the
opportunity to learn about the contents of the proposed submission, and to
comment on its contents.
If this choice is selected, the State must enter the name of the legislative
body that held the hearing in the space provided.
o Other similar process for public input that afforded interested parties the
opportunity to learn about the contents of the proposed submission, and to
comment on its contents.
If this choice is selected, the State must enter the name and a description
of the process in the spaces provided. If the State has more than one other
process the user can call up additional spaces where the required
information can be entered.
Review Criteria
The description must be sufficiently clear, detailed and complete to permit the reviewer
to determine that the State’s election meets applicable federal statutory, regulatory and
policy requirements.
•

Other Method.
If this choice is selected, the State must enter the following additional information
in the spaces provided. If the State has more than one other process the user can
call up additional spaces where the required information can be entered.
o Name of Method.
o Date. This should be entered as MM/DD/YYYY.
o Description of the Method.

Review Criteria
The description must be sufficiently clear, detailed and complete to permit the reviewer
to determine that the State’s election meets applicable federal statutory, regulatory and
policy requirements.

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Template I5 – Initial Application Data – Public Comment
If “Benchmark Alternative Benefit Plan” is selected in Template I2 – Initial
Application - Medicaid State Plan, the following statement will be displayed.
“All Public Notices include a description of the method for ensuring access to EPSDT
services under 42 CFR 440.345 and for complying with the provisions of section 5006(e)
of the American Recovery and Reinvestment Act of 2009, as required by 42 CFR
440.305(d).”
The State must affirmatively assure that its Public Notices meet the requirements in the
above statement. The State provides this affirmative assurance by checking the box next
to the above statement. Validation: If the State does not check this box, the system will
not accept this template for review and approval.
The State is then asked to either upload copies of public notices and other documents
used.
The following statement will then be displayed.
“Indicate the key issues raised during the public comment period.”
Eight topic choices for comments will then be displayed. The State should check as
many of these choices as apply. For each choice selected, the State must enter in the
spaces providedo A summary of the comments.
o A summary of the response to the comments.
Review Criteria
Each summary entered by the State must be sufficiently clear, detailed and complete to
permit the reviewer to understand the comments made and the State’s responses to
them.
The eight topic choices are:
o Access.
o Quality.
o
o
o
o

Cost.
Payment methodology.
Eligibility.
Benefits.

o Service delivery.
o Other issue.
If “Other issue” is selected, the State must enter the name of the issue and
summary of both the comments and the response to the comments in the spaces
provided. If the State has more than one other issue the user can call up
additional spaces where the required information can be entered.

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Template I5 – Initial Application Data – Public Comment
Review Criteria
Each summary entered by the State must be sufficiently clear, detailed and complete to
permit the reviewer to understand the comments made and the State’s responses to
them.

5

Template I6 – Initial Application Template – Tribal Input
INTRODUCTION
In Template I6, States provide information about tribal input and consultation pertaining
to the package they are submitting. This template applies to Medicaid State plan
amendments and amendments to a State’s CHIP program. This template must be
completed for each separate package the State is submitting.
States should complete this template in accordance with the instructions in the Technical
Guidance section below.
TECHNICAL GUIDANCE
Template I6 will display the following statement.
“One or more Indian health programs or Urban Indian Organizations furnish health care
services in the State.”
The State should enter either “Y” (Yes) or “N” (No) in the box next to this statement.
The following statement will then be displayed.
“This State Plan Amendment is likely to have a direct effect on Indians, Indian health
programs, or Urban Indian Organizations.”
The State should enter either “Y” (Yes) or “N” (No) in the box next to this statement.
If the State has entered “Y” in response to the statement above, the following statement
will be displayed.
“The State has solicited advice from Tribal governments prior to submission of this
SPA.”
The State must affirmatively assure that its submission package is in accordance with the
above statement. The State provides this affirmative assurance by checking the box next
to the above statement. Validation: If the State does not check this box, the system will
not accept this template for review and approval.
If the State entered “N” in response to the statement above, the following two additional
statements will be displayed. The State should select whichever of the two statements
applies. Only one statement can be selected.
•

“Even though not required, the State solicited advice from Tribal governments
prior to submission of this SPA.”

•

“The State has not solicited advice from Tribal governments prior to submission
of this SPA.”

If the State:
•

Selected “Y” in response to the statement “This State Plan Amendment is likely
to have a direct effect on Indians, Indian health programs, or Urban Indian
Organizations.” Or

1

Template I6 – Initial Application Template – Tribal Input
•

Selected the statement “Even though not required, the State solicited advice from
Tribal governments prior to submission of this SPA.”

The following two statements will be displayed.
“Complete the following information regarding any tribal consultation conducted with
respect to this submission.”
“Tribal consultation was conducted in the following manner:”
Three choices will then be displayed. The State should select as many of these choices
apply to this package.
•

Indian Tribes.

•

Indian Health Programs.

•

Indian Urban Organization.

For each of the choices selected, the State will be asked to enter the following
information in the spaces provided.
•

Name of the choice selected.

•

Date of consultation. This should be entered as MM/DD/YYYY.

•

Method/Location of consultation.
Review Criteria
The descriptions of the methods and locations of the consultations must be sufficiently
clear, detailed and complete to permit the reviewer to understand how the consultations
were conducted, and to determine that the State’s consultations meet applicable federal
statutory, regulatory and policy requirements.
The State is then asked to upload copies of any notices sent to Indian tribes, Indian
Health Programs, and Indian Urban Organizations.
The following statement will then be displayed.
“Indicate the key issues raised in the Indian consultative activities:”
Eight topic choices for comments will then be displayed. The State should check as
many of these choices as apply. For each choice selected, the State must enter the
following in the spaces provided.
o A summary of the comments.
o A summary of the response to the comments.
Review Criteria
Each summary entered by the State must be sufficiently clear, detailed and complete to
permit the reviewer to understand the comments made and the State’s responses to
them.
The eight topic choices are:
o Access.
o Quality.

2

Template I6 – Initial Application Template – Tribal Input
o Cost.
o Payment methodology.
o Eligibility.
o Benefits.
o Service delivery.
o Other issue.
If “Other issue” is selected, the State must enter the name of the issue and a summary of
both the comments and the State’s response to the comments in the spaces provided. If
the State has more than one other issue the user can call up additional spaces where the
required information can be entered.
Review Criteria
Each summary entered by the State must be sufficiently clear, detailed and complete to
permit the reviewer to understand the comments made and the State’s responses to
them.

3