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~ S f . , a v , c E . 8 . ( ;
DEPARTMENTOF
HEALTH
&
HUMAN
SERVICES
Centers
for
Medicare
&
Medicaid Services
:j.
Region 102201 Sixth Avenue, MS/RX 43Seattle, Washington 98121
AUf,
2
7
2009
Richard Armstrong, DirectorDepartment
of
Health and WelfareTowers Building -Tenth FloorPost Office Box 83720Boise, Idaho 83720-0036
RE: Idaho State Plan Amendment (SPA) Transmittal Number (TN) #09-009
Dear Mr. Armstrong:The Centers for Medicare
&
Medicaid Services' (CMS) Seattle Regional Office hascompleted its review
of
State Plan Amendment (SPA) Transmittal Number #09-009. Thisamendment will bring the state into compliance with CMS-2237-F regarding Targeted CaseManagement for Children.This SPA is approved effective July 1,2009.
If
you have any additional questions or require any further assistance, please contact me orhave your staff contact Priya Helweg at (206) 615-2598 or Priva.Helweg((vcms.hhs.gov.Sincerely,Barbara
K.
RichardsAssociate Regional AdministratorDivision
of
Medicaid and Children's HealthOperationscc: Leslie Clement, Administrator, Idaho Department
of
Health and Welfare
RTMENT
OF
HEALTH
AND
HUTH
CARE FINANCING
ADMIN
RANSMITTAL
AND
STATE P
R: HEALTH
CARE
FIN
: REGIONAL
ADMINIST
HEALTH CARE FINANDEPARTMENT
OF HEA
YPE
OF PLAN
MATERIANEW STATE PLANCOMPLETE
BL
EDERAL STATUTEIREG05(a)(l9)AGE
NUMBER
OF
THE
P
tion
3.1-C
Enhanced
Benc
achment
4.19-B -Pages 32SUBJECT OF AMENDME
GOVERNOR'SREVIEW
(
IZI
GOVERNOR'S
OFFIC
D
COMMENTS
OF
GOV
o
NO
REPL
Y
RECEIVE
~ ~ ~ ~ ~ ~ - -
=-=:-=---=-==-=c
HCFA-179 (07-92)
EPA
EAL
T
FO
TO5. T
o
6.
F19
g.
PSec52d
Att
10.
11.
: -
~
---
ORM
MAN
SERVICES
F
ISTRA
nON
NOTICE OF APPROVAL OFLAN MATERIAL
1.
TRANSMITTAL NUMBER:
09-009
2. ST
ID
ANCING ADMINISTRATION
3.
PROGRAM IDENTIFICATION: TITLE
XIX
SOCIAL
SECURITY
ACT (MEDICAID)
RATOR
CING ADMINISTRATION
LTH AND HUMAN
SERVICES
_______
4. PROPOSED EFFECTIVE
DATE
7/112009
L-.
L
(Check One):
D
AMENDMENT
TO
BE
CONSIDERED AS
NEW
PLAN
k8J
AOCKS
6
THRU
10
IF
THIS IS AN AMENDMENT
(Separate Transmittalfor each amendm
ULATlON CITATION:
LAN
SECTION
OR
ATTACHMENT:
hmark
Plan
-Pages 52, 52a, 52b, 52c,,
32a
7.
FEDERAL
BUDGET
IMPACT:
} I ~ e l H f f t ~
_
FFY
2 o ~ , , )
~
1I/0I.M:81 a.
....
H
..
p y 2 ~ l o =
4
9.
PAGE
NUMBER
OF
THE
SUPERSEDED P
OR
ATTACHMENT
(If
Applicable):
Section
3.1-C
Enhanced Benchmark Plan
-P
Attachment
4.19-B -Page 32NT:
To
comply with CMS-2237-C regarding Targeted Case Management.
F
(fr#)
Check One):
E
REPORTED
NOCOMMENT
D
OTHER, AS SPECIFIED:
ERNOR'S
OFFICE ENCLOSEDD WITHIN 45
DAYS OF
SUBMITTAL16. RETURN TO:Leslie M. Clement, AdministratorIdaho Department
of
Health and Welfare
- - - - - - - - - - - _ _ _ 1
Division
of
Medicaid
PO Box
83720
:-=7"".:::===----------------l
Boise
ID
83720-0036
FORREGIONALOFFICEUSEONLY .
-18.DATRAPPROVED:AUG27
D
ORM APPROVEDHOMB
NO.
0938-0193
ATE
AHO
OF
THE
_
MENDMENT
ent)
(A
\)
r·
C;1(?,
r?L
LAN SECTIONages 52
-
~
-
F
ENHANCED
PLAN
(For
Individuals
with Disabilities,
Including
Elders,
or
Special
Health
Needs)
BENCHMARK
BENEFIT
PACKAGE
provided under
EPSDT.
Needs
for
services discovered during
an
EPSDT
screening which areoutside the coverage provided by applicable Department rules must be shown
to
bemedically necessary and the least costly means
of
meeting the recipient's medical needs
to
correct or improve the physical or mental illness discovered by the screening and ordered bythe physician, nurse practitioner or physician's assistant. The Department
will
not cover.services
for
cosmetic, convenience or comfort reasons. Any service requested which iscovered under
Title
XIX
of
the Social Security Act
that
is not
identified
in applicableDepartment rules specifically
as
a covered benefit or service
will
require preauthorization.for medical necessity
prior
to payment for
that
service. Any service required
as
a result
of
an
EPSDT
screen and which is currently covered under the scope
of
the Enhanced BenchmarkBenefit Package
will
not
be subject
to
amount, scope, and duration limitations, but
will
besubject
to
prior-authorization. The additional service must be documented by the attendingphysician
as
medically necessary and
that
the service requested
is
the least costly means
of
meeting the recipient's medical needs. Preauthorization from the Department or
its
authorized agent
will
be required prior
to
payment.The Enhanced Benchmark Benefit
Package
includes
Case
Management
Services
permittedunder sections 1905(a)(19) and 2110(a)(20)
of
the Social Security Act.Target Group:• Children up
to
age
21
with
a developmental delay or disability; or• Children up
to
age
21
who have special health care
needs
requiring medical andmultidisciplinary habilitation or rehabilitation services; or• Children up
to
age
21
with
a serious emotional disturbance
(SED)
with
an
expectedduration
of
at
least one year; and•
Who
require and choose assistance
to
access
services and supports necessary to maintainindependence in the community.For
case
management services provided to individuals
in
medical institutions: [Olmstead
letter
#3]
II
Target group is comprised
of
individuals transitioning
to
a community setting and
case
management services
will
be made available
for
up
to
the last
60
consecutive
days
of
the covered stay in the medical institution.
Areas
of
State in which services
will
be provided:
. ~
Entire State
D
Only in the following geographic areas (authority
of
section 1915(g)(
1)
of
the Act
is
invoked
to
provide services
less
than Statewide)
TN
No.: 09-009Approval Date: Effective Date: 7-1-2009Supersedes TN.: 06-003
AUG
27
2009
52
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