Common use of SCHEDULE OF STATE DELIVERABLES DURING THE DEMONSTRATION Clause in Contracts

SCHEDULE OF STATE DELIVERABLES DURING THE DEMONSTRATION. Timeline Deliverable STC Reference Within 120 days from the award of the demonstration Submit Draft Evaluation Design Section IX, STC 44 Within 60 days receipt of CMS comments Submit Final Evaluation Plan Section IX, STC 45 Annually within 90 days following the end of the 4th quarter for each DY Submit Annual Report Section VI, STC 28 Quarterly within 60 days following the end of each quarter Submit Quarterly Operational Reports Section VI, STC 27 Within 180 days after the expiration of the demonstration Submit Draft Final Report Section VI, STC 28 60 days receipt of CMS comments Submit Final Report Section VI, STC 28 APPENDIX A: Template for Quarterly Operational Report [Insert Name of Demonstration] Section 1115 Quarterly Report Demonstration Year, Quarter X Fiscal Quarter Date Submitted Introduction Narrative on a brief introduction of demonstration, provide historical background from previous demonstration years and trends. Executive Summary • Brief description of demonstration populations • Goal of demonstration (list out) Demonstration Year (DY) Begin Date End Date Quarterly Report Due Date (60 days following end of quarter) Quarter 1 Quarter 2 Quarter 3 Quarter 4 • Program highlights (e.g. summary of benefits provided to the demonstration population) (Fill in chart- Indicate when each quarter begins and when it ends, see example below) • Significant program changes ▪ Narrative describing any administrative and operational changes to the demonstration, such as eligibility and enrollment processes, eligibility redetermination processes (including the option to utilize administrative redetermination), systems, health care delivery, benefits, quality of care, anticipated or proposed changes in payment rates, and outreach changes; and ▪ Narrative on any noteworthy demonstration changes, such as changes in enrollment, service utilization, education and outreach, and provider participation. Discussion of any action plan if applicable. • Policy issues and challenges ▪ Narrative providing an overview of any policy issues the state is considering, including pertinent legislative/budget activity and potential demonstration amendments; and ▪ Discussion of any action plans addressing any policy, administrative or budget issues identified, if applicable.

SCHEDULE OF STATE DELIVERABLES DURING THE DEMONSTRATION. Timeline Deliverable STC Reference Within 120 days from the award of the demonstration Submit Draft Evaluation Design Section IX, STC 44 Within 60 days receipt of CMS comments Submit Final Evaluation Plan Section IX, STC 45 Annually within 90 days following the end of the 4th quarter for each DY Submit Annual Report Section VI, STC 28 27 Quarterly within 60 days following the end of each quarter Submit Quarterly Operational Reports Section VI, STC 27 26 Within 180 days after the expiration of the demonstration Submit Draft Final Report Section VI, STC 28 60 days receipt of CMS comments Submit Final Report Section VI, STC 28 APPENDIX A: Template for Quarterly Operational Report [Insert Name of Demonstration] Section 1115 Quarterly Report Demonstration Year, Quarter X Fiscal Quarter Date Submitted Introduction Narrative on a brief introduction of demonstration, provide historical background from previous demonstration years and trends. Executive Summary •  Brief description of demonstration populations •  Goal of demonstration (list out) Demonstration Year (DY) Begin Date End Date Quarterly Report Due Date (60 days following end of quarter) Quarter 1 Quarter 2 Quarter 3 Quarter 4 •  Program highlights (e.g. summary of benefits provided to the demonstration population) (Fill in chart- Indicate when each quarter begins and when it ends, see example below) •  Significant program changes ▪  Narrative describing any administrative and operational changes to the demonstration, such as eligibility and enrollment processes, eligibility redetermination processes (including the option to utilize administrative redetermination), systems, health care delivery, benefits, quality of care, anticipated or proposed changes in payment rates, and outreach changes; and ▪  Narrative on any noteworthy demonstration changes, such as changes in enrollment, service utilization, education and outreach, and provider participation. Discussion of any action plan if applicable. •  Policy issues and challenges ▪  Narrative providing an overview of any policy issues the state is considering, including pertinent legislative/budget activity and potential demonstration amendments; and ▪  Discussion of any action plans addressing any policy, administrative or budget issues identified, if applicable.

SCHEDULE OF STATE DELIVERABLES DURING THE DEMONSTRATION. Timeline Deliverable STC Reference Within 120 days from the award of the demonstration Submit Draft Evaluation Design Section IX, STC 44 Within 60 days receipt of CMS comments Submit Final Evaluation Plan Section IX, STC 45 Annually within 90 days following the end of the 4th quarter for each DY Submit Annual Report Section VI, STC 28 27 Quarterly within 60 days following the end of each quarter Submit Quarterly Operational Reports Section VI, STC 27 26 Within 180 days after the expiration of the demonstration Submit Draft Final Report Section VI, STC 28 60 days receipt of CMS comments Submit Final Report Section VI, STC 28 APPENDIX A: Template for Quarterly Operational Report [Insert Name of Demonstration] Section 1115 Quarterly Report Demonstration Year, Quarter X Fiscal Quarter Date Submitted Introduction Narrative on a brief introduction of demonstration, provide historical background from previous demonstration years and trends. Executive Summary • Brief description of demonstration populations • Goal of demonstration (list out) Demonstration Year (DY) Begin Date End Date Quarterly Report Due Date (60 days following end of quarter) Quarter 1 Quarter 2 Quarter 3 Quarter 4 • Program highlights (e.g. summary of benefits provided to the demonstration population) (Fill in chart- Indicate when each quarter begins and when it ends, see example below) • Significant program changes ▪ Narrative describing any administrative and operational changes to the demonstration, such as eligibility and enrollment processes, eligibility redetermination processes (including the option to utilize administrative redetermination), systems, health care delivery, benefits, quality of care, anticipated or proposed changes in payment rates, and outreach changes; and ▪ Narrative on any noteworthy demonstration changes, such as changes in enrollment, service utilization, education and outreach, and provider participation. Discussion of any action plan if applicable. • Policy issues and challenges ▪ Narrative providing an overview of any policy issues the state is considering, including pertinent legislative/budget activity and potential demonstration amendments; and ▪ Discussion of any action plans addressing any policy, administrative or budget issues identified, if applicable.

SCHEDULE OF STATE DELIVERABLES DURING THE DEMONSTRATION. Timeline Deliverable STC Reference Within 120 days from the award of the demonstration Demonstration Submit Draft Evaluation Design Section IX, STC 44 Within 60 days receipt of CMS comments Submit Final Evaluation Plan Section IX, STC 45 July 1, 2012 Submit Draft Transition Plan Section VI, STC 27 Annually within 90 days following the end of the 4th quarter for each DY Submit Annual Report Section VI, STC 28 26 Quarterly within 60 days following the end of each quarter Submit Quarterly Operational Reports Section VI, STC 27 25 Within 180 days after the expiration of the demonstration Demonstration Submit Draft Final Report Section VI, STC 28 60 days receipt of CMS comments Submit Final Report Section VI, STC 28 APPENDIX A: Template for Quarterly Operational Report [Insert State Name of Demonstration] Demonstration Section 1115 Quarterly Report Demonstration Year, Quarter X Fiscal Quarter Date Submitted Introduction Narrative on a brief introduction of demonstrationDemonstration, provide historical background from previous demonstration Demonstration years and trends. Executive Summary • Brief description of demonstration populations Demonstration population • Goal of demonstration Demonstration (list out) Demonstration Year (DY) Begin Date End Date Quarterly Report Due Date (60 days following end of quarter) Quarter 1 January 1st March 31st May 30th Quarter 2 April 1st June 30th August 29th Quarter 3 July 1st September 30th November 29th Quarter 4 October 1st December 31st March 1st • Program highlights (e.g. summary of benefits provided to the demonstration Demonstration population) (Fill in chart- Indicate when each quarter begins and when it ends, see example below) • Significant program changes ▪  Narrative describing any administrative and operational changes to the demonstrationDemonstration, such as eligibility and enrollment processes, eligibility redetermination processes (including the option to utilize administrative redetermination), systems, health care delivery, benefits, quality of care, anticipated or proposed changes in payment rates, and outreach changes; and ▪  Narrative on any noteworthy demonstration Demonstration changes, such as changes in enrollment, service utilization, education and outreach, and provider participation. Discussion of any action plan if applicable. • Policy issues and challenges ▪  Narrative providing an overview of any policy issues the state State is considering, including pertinent legislative/budget activity and potential demonstration Demonstration amendments; and ▪  Discussion of any action plans addressing any policy, administrative or budget issues identified, if applicable;  Narrative on progress updates to the transition plan as specified in STC 27.