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Strengthening and Investing in Home and Community Based Services for Medicaid Beneficiaries: American Rescue Plan Act of 2021 Section 9817 Spending Plans and Narratives

Background

The COVID-19 public health emergency (PHE) has laid bare the risks of institutional and congregate settings for older adults and people with disabilities, underscoring the urgent need to reduce the reliance on institutional services and expand access to high-quality home and community-based services (HCBS) to improve outcomes for people with long-term services and supports (LTSS) needs. HCBS allow millions of Medicaid beneficiaries to receive services in their own home or community rather than institutions or other isolated settings.

Consistent with many beneficiaries’ preferences for where they would like to receive their care, HCBS have become a critical component of the Medicaid program and of broader efforts across the federal government to promote community integration of older adults and individuals with disabilities. As the primary funder of HCBS nationally, Medicaid plays a critical role in supporting states’ efforts to strengthen these services for their beneficiaries. In November 2020, CMS released a toolkit to help states to rebalance their LTSS systems by increasing the share of spending and service use delivered through HCBS, relative to spending and services provided through institutional care.

On March 11, 2021, President Biden signed the American Rescue Plan Act of 2021 (ARP) (Pub. L. 117-2). Section 9817 of the ARP provides qualifying states with a temporary 10 percentage point increase to the federal medical assistance percentage (FMAP) for certain Medicaid expenditures for HCBS beginning April 1, 2021, and ending March 31, 2022. States have until March 31, 2024 to spend the additional funding they draw down. This increased funding, an estimated $12.7 billion, represents a rare opportunity for states to identify and implement changes aimed at addressing existing HCBS workforce and structural issues, expand the capacity of critical services, and begin to meet the needs of people on HCBS waitlists and family caregivers. This funding also provides states an important opportunity to enhance individual autonomy and community integration in accordance with the home and community-based settings regulation, Olmstead implementation, and other rebalancing efforts.

Use of the Funds to Enhance, Expand, or Strengthen HCBS

CMS recognizes the significant value of these additional funds, and is committed to working with our state partners to realize these improvements in the HCBS system, both in response to the COVID-19 PHE and in response to longstanding reform priorities. While states have broad flexibility in the use of the funds, CMS strongly encourages states to use the funds to implement structural changes to:

Expand eligibility and increase access to HCBS for all Medicaid beneficiaries including those on waiting lists for HCBS waiver programs, children with disabilities, and people with behavioral health conditions;

• Offer a broader range of community-based services, particularly for people with behavioral health conditions;

Make long term investment in HCBS infrastructure, including capital investments to expand access to non-disability specific settings as part of a state’s implementation of the home and community-based settings regulation;

• Support compliance with the home and community-based settings regulatory criteria and promote community integration;

Strengthen the direct service workforce, including by increasing the pay and benefits of direct support professionals; and

Address social determinants of health and improve equity for older adults and people with disabilities.

* In addition to demonstrating enhancing, enhancing, or strengthening HCBS, any use of the funds for capital investments must result in settings that are fully compliant with the home and community-based settings criteria.

Initial Spending Plans and Narratives

CMS has received HCBS spending plans from 50 states and the District of Columbia (included in the table below). All 50 states and the District of Columbia have been fully approved to claim the HCBS FMAP increase retroactively to April 1, 2021, and to begin implementing activities in their spending plans and narratives.

States have included a number of innovative and exciting activities in their spending plans and narratives. For example, states are:

Providing recruitment and retention bonuses, pay increases, and student loan forgiveness for direct support professionals, including behavioral health providers, as well as developing certification and training programs for direct support professionals (The majority of state spending pans and narratives include workforce development initiatives);

Expanding coverage of HCBS services to those who are currently on wait lists;

Implementing in-home and mobile COVID-19 vaccination programs for people with disabilities and older adults;

Developing deed-restricted accessible and affordable housing units for people with disabilities;

Expanding access to assistive technologies to promote independence and community integration;

Expanding HCBS eligibility to children with disabilities in the TEFRA group (commonly referred to as the Katie Beckett waiver);

Implementing new behavioral health crisis response services for people with intellectual and developmental disabilities;

Providing additional home-based services to support people to return home and avoid a skilled nursing facility admission following a hospitalization;

Building partnerships to increase access to affordable and accessible housing and housing assistance for people with disabilities and older adults;

Providing housing-related services and supports, such as home accessibility modifications and case management and other supportive services to help people obtain and maintain housing; and

Developing new initiatives to increase access to competitive integrated employment for people with disabilities.

States with conditional and partial approval letters can begin to implement activities in their spending plans and narratives right away.

Future Actions

States have until March 31, 2024, to expend the state funds fully on activities aligned with the goals outlined by the ARP. See CMS’ State Medicaid Director letter implementing these requirements for more information.

In addition to the initial spending plan and narrative included below, participating states must submit quarterly HCBS spending plans and narratives to CMS on the activities that the state has implemented and/or intends to implement to enhance, expand, or strengthen HCBS under the Medicaid program.

Additional Information

For more information, contact HCBSincreasedFMAP@cms.hhs.gov.

Current State Spending Plans and Narratives (as of 12/23/2021)

This table provides:

  • Each state’s spending plan and narrative;
  • Information on whether the state has been approved to claim the FMAP increase under ARP section 9817;
  • Information on whether the proposed activities in the spending plan have been approved by CMS; and
  • Letters that CMS has issued in response to the state’s spending plan and narrative.

States are expected to update and revise their spending plans and narratives to address the questions and concerns raised by CMS in the letters. States are also expected to update and revise their spending plans and narratives on a quarterly basis as activities are implemented and as states make changes to their proposed activities.

For reference:

  • States with partial approvals have been fully approved to claim the HCBS FMAP increase retroactively to April 1, 2021. Within this category, CMS has asked the state to provide additional information before one or more proposed activities to enhance, expand, or strengthen HCBS in the state’s spending plan and narrative can be approved, and/or has identified an activity that is not approvable under ARP section 9817 (e.g., room and board). States with partial approval of their spending plans can begin implementing any activity included in the spending plan if CMS has not identified the activity as not approvable or asked for additional information about the activity.
  • States with conditional approvals have been fully approved to claim the HCBS FMAP increase retroactively to April 1, 2021, conditional upon the state’s continued compliance with program requirements as stated in SMDL #21-003. States with conditional approval of their spending plans can begin implementing all of the activities included in the spending plan.
  • States that have received a request for information did not include all required information in the state’s initial spending plan and narrative. States will need to revise and resubmit their spending plan and narrative before CMS can complete its review. Once partially or conditionally approved, states will be able to claim the HCBS FMAP increase retroactively to April 1, 2021, as described above.
State Spending Plan Approval to Claim the FMAP Increase Partial Approval Conditional Approval CMS Letters to States

AK

07/12/2021

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AK eFMAP Spending Plan Narrative (PDF, 166.1 KB)

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AK Medicaid Director Letter (PDF, 340.17 KB)

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Summary of Methodology Used (PDF, 116.24 KB)

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AK ArP FMAP Calculation Summary (PDF, 51.75 KB)

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Adjusted AK ARP eFMNAP Spending Plan (PDF, 61.74 KB)

Yes

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AK ARP 98 17 Partial 09-23-202 (PDF, 265.16 KB)

AL

07/12/2021

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AL State Spending Plan and Narrative 1 (PDF, 808.46 KB)

Yes

green checkmark

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AL ARP 9817 Partial 08-19-21 (PDF, 194.26 KB)

AR

07/12/2021

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HCBS Spending Plan Draft_DMS (9.1) (PDF, 340.79 KB)

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HCBS Spending Plan Draft Arkansas (PDF, 246.04 KB)

Yes

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AR ARP 9817 RAI 08-27-21 (PDF, 275.76 KB)

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AR ARP 9817 Conditional 09-30-21 (PDF, 197.18 KB)

AZ

07/12/2021

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Arizona AHCCCS ARPA HCBS Spending Plan (PDF, 832.02 KB)

Yes

green checkmark

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AZ ARP 9817 Partial 09-28-21 (PDF, 247.85 KB)

CA

07/12/2021
09/17/2021 (rev)

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CA HCBS Spendin Plan (PDF, 1.02 MB)

Yes

green checkmark

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CA ARP 9817 Partial 09-03-21 (PDF, 406.13 KB)

CO

06/13/2021
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CO Spending Plan for Implementation (PDF, 1.45 MB)

Yes

green checkmark

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CO ARP 9817 Partial 07-23-21 (PDF, 340.85 KB)

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CO ARP 9817 Addendum 08-02-21 (PDF, 159.13 KB)

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CO ARP 9817 Conditional 09-21-21 (PDF, 303.28 KB)

CT

07/12/2021

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CT ARP Spending Plan (PDF, 1.2 MB)

Yes

green checkmark

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CT ARP 9817 Partial 08-30-21 (PDF, 326.58 KB)

DC

07/12/2021

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DC ARPA Initial Narrative (PDF, 385.98 KB)

Yes

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DC ARP 9817 Partial 08-31-21 (PDF, 211.44 KB)

DE

07/12/2021

10/26/2021

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DE Initial HCBS Spending Plan (PDF, 600.63 KB)

Yes

green checkmark

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DE ARP 9817 RAI 08-24-21 (PDF, 273.59 KB)

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DE ARP 9817 RAI 08-24-21 (PDF, 286.72 KB)

FL

07/12/2021
09/23/2021 (rev)

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FL HCBS Spending Plan 09-23-2021 Final (PDF, 3.07 MB)

Yes

green checkmark

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FL ARP 9817 RAI 08-11-21 (PDF, 296.65 KB)

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FL ARP 9817 Conditional 09-27-21 (PDF, 247.75 KB)

GA

07/12/2021
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Georgia-ARPA Initial Spending Plan (PDF, 588.51 KB)

Yes

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GA ARP 987 Partial 09-13-21 (PDF, 389.82 KB)

HI

07/12/2021

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HI Spending Implementation (PDF, 1.38 MB)

Yes

green checkmark

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HI ARP 9817 Partial 09-14-21 (PDF, 316.83 KB)

IA

07/12/2021

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IA Medicaid ARPA BCBS Spending (PDF, 564.42 KB)

Yes

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IA ARP Partial 09-13-21 (PDF, 267.95 KB)

ID

06/14/2021

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ID Medicaid ARP Spending Plan (PDF, 650.98 KB)

Yes

green checkmark

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ID ARP 9817 Conditional 07-23-21 (PDF, 351.12 KB)

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ID ARP 9817 Addendum 08-02-21 (PDF, 161.42 KB)

IL

07/12/2021

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IL ARP HCBS Enhanced 07-12-21 (PDF, 2.03 MB)

Yes

green checkmark

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IL ARP 9817 Partial 09-29-21 (PDF, 276.39 KB)

IN

07/09/2021

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IN Medicaid HCBS FMAP (PDF, 334.58 KB)

Yes

green checkmark

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IN ARP 9817 Partial 09-30-21 (PDF, 383.41 KB)

KS

07/09/2021

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KS HCBS FMAP 10 Percent Enhancement (PDF, 76.56 KB)

Yes

green checkmark

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KS ARP 9817 Partial 09-30-21 (PDF, 226.74 KB)

KY

07/12/2021

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KY Enhanced FMAP Spending Plan (PDF, 623.54 KB)

Yes

green checkmark

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KY ARP 9817 09-30-21 (PDF, 238.02 KB)

LA

07/12/2021

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LA HCBS Cover Letter (PDF, 297.52 KB)

Yes

green checkmark

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LA ARP 9817 Partial 08-17-21 (PDF, 227.31 KB)

MA

06/17/2021

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MA ARPA HCBS Spending Plan Initial (PDF, 532.37 KB)

Yes

green checkmark

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MA ARP 9817 Partial 07-23-21 (PDF, 393.67 KB)

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MA ARP 9817 Addendum 08-02-21 (PDF, 168.21 KB)

MD

07/13/2021

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Maryland HCBS Spending Plan Final (PDF, 1.6 MB)

Yes

green checkmark

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MD ARP 9817 Partial 09-28-21 (PDF, 257.08 KB)

ME

07/09/2021

11/15/2021

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ME Updated Spending Plan (PDF, 1019.12 KB)

Yes

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ME ARP 9817 Partial 09-20-21 (PDF, 267.68 KB)

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ME ARP 9817 Conditional 11-23-21 (PDF, 162.66 KB)

MI

07/12/2021

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MDHHS HCBS Spending Plan Final (PDF, 277.06 KB)

Yes

green checkmark

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MI ARP 9817 Partial 09-30-21 (PDF, 259.07 KB)

MN

07/12/2021
08/11/2021 (rev)

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Minnesota's HCBS Spending Plan (PDF, 412.58 KB)

Yes

green checkmark

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MN ARP 9817 Partial 09-22-2021 (PDF, 437.57 KB)

MO

07/12/2021

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Missouri Initial Spending Plan (PDF, 227.34 KB)

Yes

green checkmark

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MO ARP 9817 Partial 08-13-21 (PDF, 374.44 KB)

MS

07/12/2021

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Signed MS ARPA Enhanced HCBS (PDF, 425.09 KB)

Yes

green checkmark

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MS ARP 9817 Partial 09-30-21 (PDF, 300.75 KB)

MT

07/12/2021
09/28/2021 (rev)

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Montana HCBS Spending Narrative (PDF, 449.66 KB)

Yes

green checkmark

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MT ARP 9817 RAI 08-11-21 (PDF, 288.36 KB)

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MT ARP 9817 Conditional 09-30-2021 (PDF, 244.44 KB)

NC

07/12/2021

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NC NCDHHS Spending Plan 07-12-2021 (PDF, 824.77 KB)

Yes

green checkmark

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NC ARP 9817 Partial 09-24-21 (PDF, 294.56 KB)

ND

06/11/2021

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ND State Spending Plan for Implementation (PDF, 777.56 KB)

Yes

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ND ARP 9817 Partial 07-23-21 (PDF, 334.33 KB)

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ND ARP 9817 Addendum 08-02-21 (PDF, 158.58 KB)

NE

07/12/2021

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Nebraska HCBS Spending Plan (PDF, 2.36 MB)

Yes

green checkmark

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NE ARP 9817 Partial 09-30-21 (PDF, 354.3 KB)

NH

07/09/2021

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NH HCBS Final (PDF, 3.66 MB)

Yes

green checkmark

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NH ARP 9817 Partial 09-29-21 (PDF, 221.73 KB)

NJ

07/12/2021

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New Jersey HCBS FMAP Increase Spending Plan (PDF, 400.73 KB)

Yes

green checkmark

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NJ ARP 9817 Partial 09-29-21 (PDF, 221.54 KB)

NM

07/12/2021

10/16/2021

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NM HCBS Spend Plan Cover Letter (PDF, 195.72 KB)

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NM HCBS Spending Plan with RAI Response (PDF, 617.71 KB)

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NM HCBS Spending Plan Exhibit A (PDF, 215.27 KB)

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NM HCBS Spending Plan Exhibit B (PDF, 206.99 KB)

Yes

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NM ARP 9817 RAI 09-27-21 (PDF, 287.29 KB)

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NM ARP 9817 Partial 11-05-21 (PDF, 288.88 KB)

NV

07/13/2021

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Nevada Initial Spending Plan (PDF, 757.19 KB)

Yes

green checkmark

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NV ARP 9817 Partial 09-30-21 (PDF, 365.99 KB)

NY

07/08/2021
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DRAFT NY HCBS Spending Plan Narrative (PDF, 666.38 KB)

Yes

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NY ARP 9817 Partial 08-25-21 (PDF, 313.29 KB)

OH

07/12/2021

10/19/2021

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OH Draft FINAL HCBS Spending Plan (PDF, 621.65 KB)

Yes

green checkmark

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OH ARP 9817 RAI 09-28-21 (PDF, 266.39 KB)

 PDF icon
OH ARP 9817 Partial 12-14-21 (PDF, 292.02 KB)

OK

07/15/2021

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OK ARP Initial Spending Plan 07-15-21 (PDF, 1 MB)

Yes

green checkmark

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OK ARP 9817 Partial 09-15-21 (PDF, 217.74 KB)

OR

06/11/2021

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OR OHA Letterhead (PDF, 179.39 KB)

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OHA-ODHS HCBS Enhanced Funding (PDF, 139.12 KB)

Yes

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OR ARP 9817 RAI 07-23-21 (PDF, 284.92 KB)

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OR ARP 9817 Addendum 08-02-21 (PDF, 165.89 KB)

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OR ARP 9817 Partial 09-30-21 (PDF, 344.74 KB)

PA

06/14/2021

11/15/2021

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Pennsylvania Spending Plan update (PDF, 1.46 MB)

Yes

green checkmark

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PA ARP 9817 Partial 07-23-21 (PDF, 353.2 KB) (PNG, 113.75 KB)

 PDF icon
PA ARP 9817 Addendu 08-02-21 (PDF, 160.75 KB)

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PA ARP 9817 Conditional Approval 12-01-2021 (PDF, 256 KB)

RI

07/09/2021

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RI Spending Plan ARPA HCBS (PDF, 797.84 KB)

Yes

green checkmark

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RI ARP 9817 Partial 08-09-21 (PDF, 186.7 KB)

SC

07/12/2021

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South Carolina Spending Plan (PDF, 981.39 KB)

Yes

green checkmark

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SC ARP 9817 Partial 08-11-21 (PDF, 183.64 KB)

SD

07/27/2021

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10 Percent HCBS Spending Plan 07-27-21 (PDF, 269.68 KB)

Yes

green checkmark

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SD ARP 9817 Partial 09-27-21 (PDF, 327.22 KB)

TN

07/12/2021
09/15/2021 (rev)

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TN Initial Plan for ARP Enhanced HCBS (PDF, 256.74 KB)

Yes

green checkmark

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TN ARP 9817 Partial 08-02-21 (PDF, 243.15 KB)

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TN ARP Conditional 09-22-21 (PDF, 213.36 KB)

TX

07/12/2021
09/21/2021 (rev)

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20210712_Texas Cover Letter (PDF, 240.36 KB)

Yes

green checkmark

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TX ARP 9817 Partial 08-19-21 (PDF, 205.41 KB)

UT

06/14/2021

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UT American Rescue Plan Initial Spending Plan (PDF, 390.57 KB)

Yes

green checkmark

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UT ARP 9817 Partial 07-23-21 (PDF, 379.32 KB)

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UT ARP 9817 Addendum 08-02-21 (PDF, 161.66 KB)

VA

06/11/2021

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ARP HCBS Sec 9817 FFY22Q1 Spending Plan (PDF, 346.22 KB)

Yes

green checkmark

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VA ARP RAI 07-23-21 (PDF, 350.85 KB)

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VA ARP 9817 Addendum 08-02-21 (PDF, 160.61 KB)

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VA ARP 9817 Partial 09-13-21 (PDF, 377.14 KB)

VT

06/14/2021

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Vermont HCBS FMAP Proposal (PDF, 565.94 KB)

Yes

green checkmark

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VT ARP 9817 Partial 07-23-21 (PDF, 348.21 KB)

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VT ARP 9817 Addendum 08-02-21 (PDF, 161.8 KB)

WA

06/11/2021

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WA State ARPA Spending Plan June 2021 (PDF, 478.26 KB)

Yes

green checkmark

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WA ARP 9817 RAI 07-23-21 (PDF, 297.09 KB)

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WA ARP 9817 Addendum 09-02-21 (PDF, 174.39 KB)

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WA ARP 9817 Partial 09-03-21 (PDF, 260.32 KB)

WI

06/25/2021

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Wisconsin ARPA HCBS eFAMP Plan (PDF, 262.38 KB)

Yes

green checkmark

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WI ARP 9817 RAI 08-02-21 (PDF, 291.04 KB)

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WI ARP 9817 Conditional 09-03-21 (PDF, 286.73 KB)

WV

07/12/2021
08/12/2021 (rev)

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WV State ARP HCBS Initial Spending 08-12-21 (PDF, 511.87 KB)

Yes

green checkmark

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WV ARP 9817 RAI 08-02-21 (PDF, 272.31 KB)

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WV ARP 9817 Partial 09-02-21 (PDF, 237.99 KB)

WY

07/08/2021
09/03/2021 (rev)

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Wyoming HCBS Initial Spending Plan (PDF, 2.97 MB)

Yes

green checkmark

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WY ARP 9817 Partial 08-09-21 (PDF, 180.43 KB)