The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in §1915(c) of the Social Security Act. The program permits a State to furnish an array of home and community-based services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. The State has broad discretion to design its waiver program to address the needs of the waivers target population. Waiver services complement and/or supplement the services that are available to participants through the Medicaid State plan and other federal, state and local public programs as well as the supports that families and communities provide.
The Centers for Medicare & Medicaid Services (CMS) recognizes that the design and operational features of a waiver program will vary depending on the specific needs of the target population, the resources available to the State, service delivery system structure, State goals and objectives, and other factors. A State has the latitude to design a waiver program that is cost-effective and employs a variety of service delivery approaches, including participant direction of services.
Component of the Approved Waiver | Subsection(s) |
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The waiver application consists of the following components. Note: Item 3-E must be completed.
Waiver Administration and Operation. Appendix A specifies the administrative and operational structure of this waiver.
Participant Access and Eligibility. Appendix B specifies the target group(s) of individuals who are served in this waiver, the number of participants that the State expects to serve during each year that the waiver is in effect, applicable Medicaid eligibility and post-eligibility (if applicable) requirements, and procedures for the evaluation and reevaluation of level of care.
Participant Services. Appendix C specifies the home and community-based waiver services that are furnished through the waiver, including applicable limitations on such services.
Participant-Centered Service Planning and Delivery. Appendix D specifies the procedures and methods that the State uses to develop, implement and monitor the participant-centered service plan (of care).
Participant Rights. Appendix F specifies how the State informs participants of their Medicaid Fair Hearing rights and other procedures to address participant grievances and complaints.
Participant Safeguards. Appendix G describes the safeguards that the State has established to assure the health and welfare of waiver participants in specified areas.
Quality Improvement Strategy. Appendix H contains the Quality Improvement Strategy for this waiver.
Financial Accountability. Appendix I describes the methods by which the State makes payments for waiver services, ensures the integrity of these payments, and complies with applicable federal requirements concerning payments and federal financial participation.
Cost-Neutrality Demonstration. Appendix J contains the State's demonstration that the waiver is cost-neutral.
Health & Welfare: The State assures that necessary safeguards have been taken to protect the health and welfare of persons receiving services under this waiver. These safeguards include:
As specified in Appendix C, adequate standards for all types of providers that provide services under this waiver;
Assurance that the standards of any State licensure or certification requirements specified in Appendix C are met for services or for individuals furnishing services that are provided under the waiver. The State assures that these requirements are met on the date that the services are furnished; and,
Assurance that all facilities subject to §1616(e) of the Act where home and community-based waiver services are provided comply with the applicable State standards for board and care facilities as specified in Appendix C.
Financial Accountability. The State assures financial accountability for funds expended for home and community-based services and maintains and makes available to the Department of Health and Human Services (including the Office of the Inspector General), the Comptroller General, or other designees, appropriate financial records documenting the cost of services provided under the waiver. Methods of financial accountability are specified in Appendix I.
Evaluation of Need: The State assures that it provides for an initial evaluation (and periodic reevaluations, at least annually) of the need for a level of care specified for this waiver, when there is a reasonable indication that an individual might need such services in the near future (one month or less) but for the receipt of home and community-based services under this waiver. The procedures for evaluation and reevaluation of level of care are specified in Appendix B.
Choice of Alternatives: The State assures that when an individual is determined to be likely to require the level of care specified for this waiver and is in a target group specified in Appendix B, the individual (or, legal representative, if applicable) is:
Informed of any feasible alternatives under the waiver; and,
Given the choice of either institutional or home and community-based waiver services. Appendix B specifies the procedures that the State employs to ensure that individuals are informed of feasible alternatives under the waiver and given the choice of institutional or home and community-based waiver services.
Average Per Capita Expenditures: The State assures that, for any year that the waiver is in effect, the average per capita expenditures under the waiver will not exceed 100 percent of the average per capita expenditures that would have been made under the Medicaid State plan for the level(s) of care specified for this waiver had the waiver not been granted. Cost-neutrality is demonstrated in Appendix J.
Actual Total Expenditures: The State assures that the actual total expenditures for home and community-based waiver and other Medicaid services and its claim for FFP in expenditures for the services provided to individuals under the waiver will not, in any year of the waiver period, exceed 100 percent of the amount that would be incurred in the absence of the waiver by the State's Medicaid program for these individuals in the institutional setting(s) specified for this waiver.
Institutionalization Absent Waiver: The State assures that, absent the waiver, individuals served in the waiver would receive the appropriate type of Medicaid-funded institutional care for the level of care specified for this waiver.
Reporting: The State assures that annually it will provide CMS with information concerning the impact of the waiver on the type, amount and cost of services provided under the Medicaid State plan and on the health and welfare of waiver participants. This information will be consistent with a data collection plan designed by CMS.
Habilitation Services. The State assures that prevocational, educational, or supported employment services, or a combination of these services, if provided as habilitation services under the waiver are: (1) not otherwise available to the individual through a local educational agency under the Individuals with Disabilities Education Act (IDEA) or the Rehabilitation Act of 1973; and, (2) furnished as part of expanded habilitation services.
Services for Individuals with Chronic Mental Illness. The State assures that federal financial participation (FFP) will not be claimed in expenditures for waiver services including, but not limited to, day treatment or partial hospitalization, psychosocial rehabilitation services, and clinic services provided as home and community-based services to individuals with chronic mental illnesses if these individuals, in the absence of a waiver, would be placed in an IMD and are: (1) age 22 to 64; (2) age 65 and older and the State has not included the optional Medicaid benefit cited in 42 CFR §440.140; or (3) age 21 and under and the State has not included the optional Medicaid benefit cited in 42 CFR § 440.160.
Service Plan. In accordance with 42 CFR §441.301(b)(1)(i), a participant-centered service plan (of care) is developed for each participant employing the procedures specified in Appendix D. All waiver services are furnished pursuant to the service plan. The service plan describes: (a) the waiver services that are furnished to the participant, their projected frequency and the type of provider that furnishes each service and (b) the other services (regardless of funding source, including State plan services) and informal supports that complement waiver services in meeting the needs of the participant. The service plan is subject to the approval of the Medicaid agency. Federal financial participation (FFP) is not claimed for waiver services furnished prior to the development of the service plan or for services that are not included in the service plan.
Inpatients. In accordance with 42 CFR §441.301(b)(1)(ii), waiver services are not furnished to individuals who are in-patients of a hospital, nursing facility or ICF/IID.
Room and Board. In accordance with 42 CFR §441.310(a)(2), FFP is not claimed for the cost of room and board except when: (a) provided as part of respite services in a facility approved by the State that is not a private residence or (b) claimed as a portion of the rent and food that may be reasonably attributed to an unrelated caregiver who resides in the same household as the participant, as provided in Appendix I.
Access to Services. The State does not limit or restrict participant access to waiver services except as provided in Appendix C.
Free Choice of Provider. In accordance with 42 CFR §431.151, a participant may select any willing and qualified provider to furnish waiver services included in the service plan unless the State has received approval to limit the number of providers under the provisions of §1915(b) or another provision of the Act.
FFP Limitation. In accordance with 42 CFR §433 Subpart D, FFP is not claimed for services when another third-party (e.g., another third party health insurer or other federal or state program) is legally liable and responsible for the provision and payment of the service. FFP also may not be claimed for services that are available without charge, or as free care to the community. Services will not be considered to be without charge, or free care, when (1) the provider establishes a fee schedule for each service available and (2) collects insurance information from all those served (Medicaid, and non-Medicaid), and bills other legally liable third party insurers. Alternatively, if a provider certifies that a particular legally liable third party insurer does not pay for the service(s), the provider may not generate further bills for that insurer for that annual period.
Fair Hearing: The State provides the opportunity to request a Fair Hearing under 42 CFR §431 Subpart E, to individuals: (a) who are not given the choice of home and community-based waiver services as an alternative to institutional level of care specified for this waiver; (b) who are denied the service(s) of their choice or the provider(s) of their choice; or (c) whose services are denied, suspended, reduced or terminated. Appendix F specifies the State's procedures to provide individuals the opportunity to request a Fair Hearing, including providing notice of action as required in 42 CFR §431.210.
Quality Improvement. The State operates a formal, comprehensive system to ensure that the waiver meets the assurances and other requirements contained in this application. Through an ongoing process of discovery, remediation and improvement, the State assures the health and welfare of participants by monitoring: (a) level of care determinations; (b) individual plans and services delivery; (c) provider qualifications; (d) participant health and welfare; (e) financial oversight and (f) administrative oversight of the waiver. The State further assures that all problems identified through its discovery processes are addressed in an appropriate and timely manner, consistent with the severity and nature of the problem. During the period that the waiver is in effect, the State will implement the Quality Improvement Strategy specified in Appendix H.
Notice to Tribal Governments. The State assures that it has notified in writing all federally-recognized Tribal Governments that maintain a primary office and/or majority population within the State of the State's intent to submit a Medicaid waiver request or renewal request to CMS at least 60 days before the anticipated submission date is provided by Presidential Executive Order 13175 of November 6, 2000. Evidence of the applicable notice is available through the Medicaid Agency.
Limited English Proficient Persons. The State assures that it provides meaningful access to waiver services by Limited English Proficient persons in accordance with: (a) Presidential Executive Order 13166 of August 11, 2000 (65 FR 50121) and (b) Department of Health and Human Services "Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons" (68 FR 47311 - August 8, 2003). Appendix B describes how the State assures meaningful access to waiver services by Limited English Proficient persons.
State Medicaid Director or Designee
State Line of Authority for Waiver Operation. Specify the state line of authority for the operation of the waiver (select one):
Specify the Medicaid agency division/unit that has line authority for the operation of the waiver program (select one):
In accordance with 42 CFR §431.10, the Medicaid agency exercises administrative discretion in the administration and supervision of the waiver and issues policies, rules and regulations related to the waiver. The interagency agreement or memorandum of understanding that sets forth the authority and arrangements for this policy is available through the Medicaid agency to CMS upon request. (Complete item A-2-b).
Oversight of Performance.
Role of Local/Regional Non-State Entities. Indicate whether local or regional non-state entities perform waiver operational and administrative functions and, if so, specify the type of entity (Select One):
Function | Medicaid Agency | Contracted Entity |
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Participant waiver enrollment | ||
Waiver enrollment managed against approved limits | ||
Waiver expenditures managed against approved levels | ||
Level of care evaluation | ||
Review of Participant service plans | ||
Prior authorization of waiver services | ||
Utilization management | ||
Qualified provider enrollment | ||
Execution of Medicaid provider agreements | ||
Establishment of a statewide rate methodology | ||
Rules, policies, procedures and information development governing the waiver program | ||
Quality assurance and quality improvement activities |
Performance Measures
Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Participants are supported by competent and qualified case managers. (Number of Case Managers with a rating of “meets expectations” or “exceeds expectations” on their performance evaluations/ Number of Case Managers due for performance evaluation
Data Aggregation and Analysis:
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Performance Measure:
The ASO reviews waiver service providers in accordance with the requirements and schedule outlined in the contact with the Medicaid Agency. (Number of service provider reviews conducted by ASO/ Number of service provider reviews due for review)
Data Aggregation and Analysis:
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Performance Measure:
OOM, MRC and the Fiscal Management Service agencies (FMS) work collaboratively to ensure systematic and continuous data collection and analysis of the FMS entity functions and systems as evidenced by the timely and appropriate submission of required data reports.
(Number of FMS reports submitted on time and in the correct format/ Number of FMS reports due)
Data Aggregation and Analysis:
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Performance Measure:
% of annual redeterminations with a completed Waiver LOC determination instrument before the end of 365 days. (Number of annual redeterminations with a completed Waiver LOC determination instrument before the end of 365 days/ Total number of individuals needing annual redeterminations)
Data Aggregation and Analysis:
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Responsible Party(check each that applies): | Frequency of data aggregation and analysis(check each that applies): |
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Target Group | Included | Target SubGroup | Minimum Age | Maximum Age | |
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Maximum Age Limit | No Maximum Age Limit | ||||
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Aged | |||||
Disabled (Physical) | |||||
Disabled (Other) | |||||
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Brain Injury | |||||
HIV/AIDS | |||||
Medically Fragile | |||||
Technology Dependent | |||||
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Autism | |||||
Developmental Disability | |||||
Intellectual Disability | |||||
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Mental Illness | |||||
Serious Emotional Disturbance | |||||
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The limit specified by the State is (select one)
The cost limit specified by the State is (select one):
The dollar amount (select one)
Answers provided in Appendix B-2-a indicate that you do not need to complete this section.
Waiver Year | Unduplicated Number of Participants |
Year 1 | |
Year 2 | |
Year 3 | |
Year 4 | |
Year 5 |
Waiver Year | Maximum Number of Participants Served At Any Point During the Year |
Year 1 | |
Year 2 | |
Year 3 | |
Year 4 | |
Year 5 |
Purposes | ![]() |
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Waiver Transfer |
Appendix B: Participant Access and EligibilityB-3: Number of Individuals Served (2 of 4)
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Select one:
Answers provided in Appendix B-3-d indicate that you do not need to complete this section.
Select one:
Check each that applies:
Select one:
Select one:
In accordance with 42 CFR §441.303(e), Appendix B-5 must be completed when the State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217, as indicated in Appendix B-4. Post-eligibility applies only to the 42 CFR §435.217 group.
Use of Spousal Impoverishment Rules. Indicate whether spousal impoverishment rules are used to determine eligibility for the special home and community-based waiver group under 42 CFR §435.217:
In the case of a participant with a community spouse, the State elects to (select one):
Regular Post-Eligibility Treatment of Income: SSI State.
The State uses the post-eligibility rules at 42 CFR 435.726. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the following allowances and expenses from the waiver participant's income:
Allowance for the needs of the waiver participant (select one):
Select one:
(select one):
Allowance for the spouse only (select one):
Allowance for the family (select one):
Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 §CFR 435.726:
Select one:
Regular Post-Eligibility Treatment of Income: 209(B) State.
Answers provided in Appendix B-4 indicate that you do not need to complete this section and therefore this section is not visible.
Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules
The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care if it determines the individual's eligibility under §1924 of the Act. There is deducted from the participant's monthly income a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the State Medicaid Plan. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).
Regular Post-Eligibility Treatment of Income: §1634 State - 2014 through 2018.
The State uses the post-eligibility rules at 42 CFR §435.726 for individuals who do not have a spouse or have a spouse who is not a community spouse as specified in §1924 of the Act. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the following allowances and expenses from the waiver participant's income:
Allowance for the needs of the waiver participant (select one):
Select one:
(select one):
Allowance for the spouse only (select one):
Specify the amount of the allowance (select one):
Allowance for the family (select one):
Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 §CFR 435.726:
Select one:
Regular Post-Eligibility Treatment of Income: 209(B) State - 2014 through 2018.
Answers provided in Appendix B-4 indicate that you do not need to complete this section and therefore this section is not visible.
Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules - 2014 through 2018.
The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care. There is deducted from the participant's monthly income a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the State Medicaid Plan. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).
Allowance for the personal needs of the waiver participant
(select one):
If the allowance for the personal needs of a waiver participant with a community spouse is different from the amount used for the individual's maintenance allowance under 42 CFR §435.726 or 42 CFR §435.735, explain why this amount is reasonable to meet the individual's maintenance needs in the community.
Select one:
Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 CFR §435.726:
Select one:
Reasonable Indication of Need for Services. In order for an individual to be determined to need waiver services, an individual must require: (a) the provision of at least one waiver service, as documented in the service plan, and (b) the provision of waiver services at least monthly or, if the need for services is less than monthly, the participant requires regular monthly monitoring which must be documented in the service plan. Specify the State's policies concerning the reasonable indication of the need for services:
Minimum number of services.
The state demonstrates that it implements the processes and instrument(s) specified in its approved waiver for evaluating/reevaluating an applicant's/waiver participant's level of care consistent with level of care provided in a hospital, NF or ICF/IID.
Sub-assurance: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
% of applicants who received an initial clinical eligibility assessment within 90 days of waiver application. (Number of individuals who received an initial clinical eligibility assessment within 90 days of waiver application/ Number of individuals who received an initial clinical eligibility assessment)
Data Aggregation and Analysis:
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Sub-assurance: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
No longer needed in new QM system
Data Aggregation and Analysis:
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Sub-assurance: The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant level of care.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
% of applicants whose clinical eligibility assessment is documented in accordance with waiver requirements. (Number of applicants whose clinical eligibility assessment was documented in accordance with waiver requirements/ Number of applicants whose clinical eligibility assessment was documented)
Data Aggregation and Analysis:
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Performance Measure:
% of clinical determinations of "denial" that have been reviewed for appropriateness of denial. (Number of denials reviewed/ Number of denials)
Data Aggregation and Analysis:
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Responsible Party(check each that applies): | Frequency of data aggregation and analysis(check each that applies): |
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Service Type | Service | ![]() | ![]() |
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Statutory Service | Home Health Aide | ||
Statutory Service | Homemaker | ||
Statutory Service | Personal Care | ||
Statutory Service | Prevocational Services | ||
Statutory Service | Respite | ||
Statutory Service | Supported Employment | ||
Other Service | Addiction Services | ||
Other Service | Adult Companion | ||
Other Service | Chore Service | ||
Other Service | Community Crisis Stabilization | ||
Other Service | Community Family Training | ||
Other Service | Community Psychiatric Support and Treatment (CPST) | ||
Other Service | Day Services | ||
Other Service | Home Accessibility Adaptations | ||
Other Service | Independent Living Supports | ||
Other Service | Individual Support and Community Habilitation | ||
Other Service | Medication Administration | ||
Other Service | Occupational Therapy | ||
Other Service | Peer Support | ||
Other Service | Physical Therapy | ||
Other Service | Shared Home Supports | ||
Other Service | Skilled Nursing | ||
Other Service | Specialized Medical Equipment | ||
Other Service | Speech Therapy | ||
Other Service | Supportive Home Care Aide | ||
Other Service | Transportation | ||
Other Service | Vehicle Modification |
Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Delivery of Case Management Services.
Criminal History and/or Background Investigations.
Abuse Registry Screening.
Services in Facilities Subject to §1616(e) of the Social Security Act. Select one:
Facility Type | ![]() |
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Assisted Living Residences | |
DDS Licensed Respite Facilities | |
Skilled Nursing Facilities | |
Hospitals | |
Rest Homes |
Appendix C: Participant ServicesC-2: Facility Specifications
Scope of Facility Sandards. For this facility type, please specify whether the State's standards address the following topics (check each that applies):
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Appendix C: Participant ServicesC-2: Facility Specifications
Scope of Facility Sandards. For this facility type, please specify whether the State's standards address the following topics (check each that applies):
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Appendix C: Participant ServicesC-2: Facility Specifications
Scope of Facility Sandards. For this facility type, please specify whether the State's standards address the following topics (check each that applies):
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Appendix C: Participant ServicesC-2: Facility Specifications
Scope of Facility Sandards. For this facility type, please specify whether the State's standards address the following topics (check each that applies):
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Appendix C: Participant ServicesC-2: Facility Specifications
Scope of Facility Sandards. For this facility type, please specify whether the State's standards address the following topics (check each that applies):
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Provision of Personal Care or Similar Services by Legally Responsible Individuals. A legally responsible individual is any person who has a duty under State law to care for another person and typically includes: (a) the parent (biological or adoptive) of a minor child or the guardian of a minor child who must provide care to the child or (b) a spouse of a waiver participant. Except at the option of the State and under extraordinary circumstances specified by the State, payment may not be made to a legally responsible individual for the provision of personal care or similar services that the legally responsible individual would ordinarily perform or be responsible to perform on behalf of a waiver participant. Select one:
Other State Policies Concerning Payment for Waiver Services Furnished by Relatives/Legal Guardians. Specify State policies concerning making payment to relatives/legal guardians for the provision of waiver services over and above the policies addressed in Item C-2-d. Select one:
Open Enrollment of Providers.
The state demonstrates that it has designed and implemented an adequate system for assuring that all waiver services are provided by qualified providers.
Sub-Assurance: The State verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other standards prior to their furnishing waiver services.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
% of new agency providers, licensed by DDS, that received an initial license to provide supports. (Number of new agency providers that received a license to operate within 6 months of initial review/ Number of new agency providers that were selected to provide support)
Data Aggregation and Analysis:
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Performance Measure:
% of licensed or certified providers credentialed by the Provider Network Administration/Massachusetts Rehabilitation Commission that initially meet applicable licensure or certification requirements. (Number of licensed or certified providers with appropriate credentials/ Number of licensed or certified providers)
Data Aggregation and Analysis:
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Performance Measure:
% of providers licensed by DDS that continue to meet applicable licensure or certification standards. (Number of providers that continue to meet applicable licensure or certification standards/ Number of providers subject to licensure/certification)
Data Aggregation and Analysis:
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Performance Measure:
% of licensed/certified providers credentialed by the Provider Network Administration/Massachusetts Rehabilitation Commission who continue to meet applicable licensure/certification requirements.(Number of licensed/certified providers who continue to meet applicable licensure requirements/Number of licensed/certified providers who are required to have applicable state licensure/certification)
Data Aggregation and Analysis:
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Performance Measure:
% of agency providers licensed by DDS that have corrected identified deficiencies. (Number of providers that have corrected deficiencies/ Number of providers with identified deficiencies)
Data Aggregation and Analysis:
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Performance Measure:
% of licensed or certified providers credentialed by the Provider Network Administration/Massachusetts Rehabilitation Commission that have corrected identified findings. (Number of licensed or certified providers that have corrected identified findings/ Total number of licensed or certified providers that have findings)
Data Aggregation and Analysis:
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Sub-Assurance: The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements.
For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
% of providers not subject to licensure or certification who are offering services who initially meet requirements to provide supports. (Number of providers not subject to licensure or certification who initially meet the qualification requirements to provide services/ Number of providers)
Data Aggregation and Analysis:
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Performance Measure:
% of providers who are not subject to licensure or certification who continue to meet qualifications to provide services. (Number of providers who continue to meet requirements/ Total number of providers not subject to licensure or certification)
Data Aggregation and Analysis:
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Performance Measure:
% of providers who are not subject to licensure or certification who have corrected identified findings. (Number of providers who are not subject to licensure or certification that have corrected all identified findings/ Total number of providers who are not subject to licensure or certification that have findings)
Data Aggregation and Analysis:
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Sub-Assurance: The State implements its policies and procedures for verifying that provider training is conducted in accordance with state requirements and the approved waiver.
For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
% of DDS licensed/certified providers that have staff trained and current in required trainings including medication administration, CPR, first aid, restraint utilization and abuse/neglect reporting. (Number of DDS licensed/certified providers that have staff trained/ Number of DDS licensed/certified providers reviewed through survey and certification)
Data Aggregation and Analysis:
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Performance Measure:
% of providers that are not subject to DDS licensure and/or certification that have been trained and are current in all required trainings. (Number of providers (not subject to DDS licensure and/or certification) that have been trained/ Number of providers reviewed)
Data Aggregation and Analysis:
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Responsible Party(check each that applies): | Frequency of data aggregation and analysis(check each that applies): |
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Section C-3 'Service Specifications' is incorporated into Section C-1 'Waiver Services.'
Additional Limits on Amount of Waiver Services. Indicate whether the waiver employs any of the following additional limits on the amount of waiver services (select one).
When a limit is employed, specify: (a) the waiver services to which the limit applies; (b) the basis of the limit, including its basis in historical expenditure/utilization patterns and, as applicable, the processes and methodologies that are used to determine the amount of the limit to which a participant's services are subject; (c) how the limit will be adjusted over the course of the waiver period; (d) provisions for adjusting or making exceptions to the limit based on participant health and welfare needs or other factors specified by the state; (e) the safeguards that are in effect when the amount of the limit is insufficient to meet a participant's needs; (f) how participants are notified of the amount of the limit. (check each that applies)
Description of the settings and how they meet federal HCB Settings requirements, at the time of submission and in the future.
Description of the means by which the state Medicaid agency ascertains that all waiver settings meet federal HCB Setting requirements, at the time of this submission and ongoing.
The state demonstrates it has designed and implemented an effective system for reviewing the adequacy of service plans for waiver participants.
Sub-assurance: Service plans address all participants assessed needs (including health and safety risk factors) and personal goals, either by the provision of waiver services or through other means.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
% of service plans that reflect needs identified through the assessment process. (Number of service plans that address needs identified during the assessment process/ Number of service plans reviewed)
Data Aggregation and Analysis:
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Performance Measure:
% of service plans that reflect personal goals identified through the assessment process. (Number of service plans that address personal goals identified during the assessment process/ Number of service plans reviewed)
Data Aggregation and Analysis:
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Performance Measure:
% of service plans that have been developed in accordance with waiver requirements as indicated by the inclusion of all required components, including all required assessments, support strategies, choice forms, LOC & POC. (Number of service plans developed in accordance with waiver requirements as indicated by the inclusion of all required components/ Number of service plans reviewed)
Data Aggregation and Analysis:
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Performance Measure:
% of service plans in which communication and contact has been maintained as required to assure that services are being provided and meet the person’s needs. (Number of service plans in which communication and contact has been maintained as required to assure that services are being provided and meet the person’s needs / Number of service plans reviewed)
Data Aggregation and Analysis:
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Sub-assurance: The State monitors service plan development in accordance with its policies and procedures.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
No longer needed in new QM system
Data Aggregation and Analysis:
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Sub-assurance: Service plans are updated/revised at least annually or when warranted by changes in the waiver participants needs.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
% of service plans that are completed and/or updated annually. (Number of service plans completed and/or updated annually/ Number of service plans reviewed)
Data Aggregation and Analysis:
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Performance Measure:
% of service plans updated when warranted by changes in participants’ needs. (Number of service plans updated when needs change/ Number of participants reviewed with changing needs)
Data Aggregation and Analysis:
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Sub-assurance: Services are delivered in accordance with the service plan, including the type, scope, amount, duration and frequency specified in the service plan.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
% of individuals who are receiving services according to the type, amount, frequency and duration identified in their plan of care. (Number of individuals who are receiving services according to the type, amount, frequency and duration in their plan of care/ Number of individual plans of care reviewed)
Data Aggregation and Analysis:
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Sub-assurance: Participants are afforded choice: Between waiver services and institutional care; and between/among waiver services and providers.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
% of service plans that contain documentation indicating that participant was informed of his/her choice between service providers and method of service delivery. (Number of service plans that contain documentation indicating that participant was informed of his/her choice between service providers and method of service delivery/ Number of service plans reviewed)
Data Aggregation and Analysis:
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Responsible Party(check each that applies): | Frequency of data aggregation and analysis(check each that applies): |
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Applicability (from Application Section 3, Components of the Waiver Request):
CMS urges states to afford all waiver participants the opportunity to direct their services. Participant direction of services includes the participant exercising decision-making authority over workers who provide services, a participant-managed budget or both. CMS will confer the Independence Plus designation when the waiver evidences a strong commitment to participant direction.
Indicate whether Independence Plus designation is requested (select one):
Description of Participant Direction.
Participant Direction Opportunities. Specify the participant direction opportunities that are available in the waiver. Select one:
Availability of Participant Direction by Type of Living Arrangement. Check each that applies:
Election of Participant Direction.
Information Furnished to Participant.
Participant Direction by a Representative.
Specify the representatives who may direct waiver services: (check each that applies):
Participant-Directed Services.
Waiver Service | Employer Authority | Budget Authority |
---|---|---|
Adult Companion | ||
Chore Service | ||
Homemaker | ||
Individual Support and Community Habilitation | ||
Personal Care | ||
Peer Support |
Financial Management Services. Except in certain circumstances, financial management services are mandatory and integral to participant direction. A governmental entity and/or another third-party entity must perform necessary financial transactions on behalf of the waiver participant. Select one:
Specify whether governmental and/or private entities furnish these services. Check each that applies:
Provision of Financial Management Services. Financial management services (FMS) may be furnished as a waiver service or as an administrative activity. Select one:
Provide the following information
Types of Entities:
Payment for FMS.
Scope of FMS. Specify the scope of the supports that FMS entities provide (check each that applies):
Supports furnished when the participant is the employer of direct support workers:
Supports furnished when the participant exercises budget authority:
Additional functions/activities:
Oversight of FMS Entities.
Information and Assistance in Support of Participant Direction. In addition to financial management services, participant direction is facilitated when information and assistance are available to support participants in managing their services. These supports may be furnished by one or more entities, provided that there is no duplication. Specify the payment authority (or authorities) under which these supports are furnished and, where required, provide the additional information requested (check each that applies):
Participant-Directed Waiver Service | Information and Assistance Provided through this Waiver Service Coverage |
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Day Services | |
Community Family Training | |
Independent Living Supports | |
Home Accessibility Adaptations | |
Medication Administration | |
Addiction Services | |
Community Psychiatric Support and Treatment (CPST) | |
Adult Companion | |
Vehicle Modification | |
Chore Service | |
Community Crisis Stabilization | |
Transportation | |
Specialized Medical Equipment | |
Prevocational Services | |
Supported Employment | |
Skilled Nursing | |
Respite | |
Supportive Home Care Aide | |
Speech Therapy | |
Occupational Therapy | |
Homemaker | |
Individual Support and Community Habilitation | |
Home Health Aide | |
Physical Therapy | |
Shared Home Supports | |
Personal Care | |
Peer Support |
Independent Advocacy (select one).
Voluntary Termination of Participant Direction.
Involuntary Termination of Participant Direction.
Goals for Participant Direction. In the following table, provide the State's goals for each year that the waiver is in effect for the unduplicated number of waiver participants who are expected to elect each applicable participant direction opportunity. Annually, the State will report to CMS the number of participants who elect to direct their waiver services.
Employer Authority Only | Budget Authority Only or Budget Authority in Combination with Employer Authority | |
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Waiver Year | Number of Participants | Number of Participants |
Year 1 | ||
Year 2 | ||
Year 3 | ||
Year 4 | ||
Year 5 |
Participant - Employer Authority Complete when the waiver offers the employer authority opportunity as indicated in Item E-1-b:
Participant Employer Status. Specify the participant's employer status under the waiver. Select one or both:
Participant Decision Making Authority. The participant (or the participant's representative) has decision making authority over workers who provide waiver services. Select one or more decision making authorities that participants exercise:
Participant - Budget Authority Complete when the waiver offers the budget authority opportunity as indicated in Item E-1-b:
Answers provided in Appendix E-1-b indicate that you do not need to complete this section.
Participant Decision Making Authority. When the participant has budget authority, indicate the decision-making authority that the participant may exercise over the budget. Select one or more:
Participant - Budget Authority
Answers provided in Appendix E-1-b indicate that you do not need to complete this section.
Participant-Directed Budget
Participant - Budget Authority
Answers provided in Appendix E-1-b indicate that you do not need to complete this section.
Informing Participant of Budget Amount.
Participant - Budget Authority
Answers provided in Appendix E-1-b indicate that you do not need to complete this section.
Participant Exercise of Budget Flexibility. Select one:
Participant - Budget Authority
Answers provided in Appendix E-1-b indicate that you do not need to complete this section.
Expenditure Safeguards.
The State provides an opportunity to request a Fair Hearing under 42 CFR Part 431, Subpart E to individuals: (a) who are not given the choice of home and community-based services as an alternative to the institutional care specified in Item 1-F of the request; (b) are denied the service(s) of their choice or the provider(s) of their choice; or, (c) whose services are denied, suspended, reduced or terminated. The State provides notice of action as required in 42 CFR §431.210.
Procedures for Offering Opportunity to Request a Fair Hearing.
Availability of Additional Dispute Resolution Process. Indicate whether the State operates another dispute resolution process that offers participants the opportunity to appeal decisions that adversely affect their services while preserving their right to a Fair Hearing. Select one:
Description of Additional Dispute Resolution Process.
Operation of Grievance/Complaint System. Select one:
Operational Responsibility.
Description of System.
Critical Event or Incident Reporting and Management Process.
State Critical Event or Incident Reporting Requirements.
Participant Training and Education.
Responsibility for Review of and Response to Critical Events or Incidents.
Responsibility for Oversight of Critical Incidents and Events.
Use of Restraints. (Select one): (For waiver actions submitted before March 2014, responses in Appendix G-2-a will display information for both restraints and seclusion. For most waiver actions submitted after March 2014, responses regarding seclusion appear in Appendix G-2-c.)
Safeguards Concerning the Use of Restraints.
State Oversight Responsibility.
Use of Restrictive Interventions. (Select one):
Safeguards Concerning the Use of Restrictive Interventions.
State Oversight Responsibility.
Use of Seclusion. (Select one): (This section will be blank for waivers submitted before Appendix G-2-c was added to WMS in March 2014, and responses for seclusion will display in Appendix G-2-a combined with information on restraints.)
Safeguards Concerning the Use of Seclusion.
State Oversight Responsibility.
This Appendix must be completed when waiver services are furnished to participants who are served in licensed or unlicensed living arrangements where a provider has round-the-clock responsibility for the health and welfare of residents. The Appendix does not need to be completed when waiver participants are served exclusively in their own personal residences or in the home of a family member.
Applicability. Select one:
Medication Management and Follow-Up
Responsibility.
Methods of State Oversight and Follow-Up.
Medication Administration by Waiver Providers
Provider Administration of Medications. Select one:
State Policy.
Medication Error Reporting. Select one of the following:
State Oversight Responsibility.
Sub-assurance: The state demonstrates on an ongoing basis that it identifies, addresses and seeks to prevent instancesof abuse, neglect, exploitation and unexplained death. (Performance measures in this sub-assurance include all Appendix G performance measures for waiver actions submitted before June 1, 2014.)
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
No. and rate of substantiated investigations by type. (Number of substantiated investigations by type/ Number of total adults served and rate per 100 adults)
Data Aggregation and Analysis:
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Performance Measure:
% of intakes screened in for investigation of abuse where the need for protective services were reviewed as recommended. (Number of intakes screened in for investigation of abuse where the need for protective services were reviewed/ Total number of intakes where a review for protective services were recommended by the senior investigator)
Data Aggregation and Analysis:
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Performance Measure:
% of participants who received information about how to report abuse and/or neglect (Number of participants who received information about how to report abuse and/or neglect/ Number of participants reviewed)
Data Aggregation and Analysis:
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Performance Measure:
% of deaths that are required to have a clinical review that received a clinical review. (Number of deaths that have a clinical review/ Total number of deaths required to have a clinical review)
Data Aggregation and Analysis:
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Performance Measure:
% of providers who conduct CORI’s of prospective employees and take appropriate action when necessary. (Number of providers that conduct CORI's of prospective employees and take required action/ Total number of providers reviewed)
Data Aggregation and Analysis:
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Sub-assurance: The state demonstrates that an incident management system is in place that effectively resolves those incidents and prevents further similar incidents to the extent possible.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
% of incident “trigger” reports that have had follow up action taken. (Number of incidents that reach the "trigger" threshold for which action has been taken/ Total number of incidents that reach the "trigger" threshold)
Data Aggregation and Analysis:
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Performance Measure:
% of action/safety plans implemented. (number of action/safety plans implemented for substantiated investigations/ Number of action/safety plans written)
Data Aggregation and Analysis:
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Sub-assurance: The state policies and procedures for the use or prohibition of restrictive interventions (including restraints and seclusion) are followed.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
% of restrictive interventions that were reported appropriately. (Number of restrictive interventions reported appropriately/ Number of restrictive interventions)
Data Aggregation and Analysis:
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Sub-assurance: The state establishes overall health care standards and monitors those standards based on the responsibility of the service provider as stated in the approved waiver.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
% of participants who have identified a primary care provider. (Number of individuals with a documented primary care provider/ Number of individuals reviewed)
Data Aggregation and Analysis:
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Responsible Party(check each that applies): | Frequency of data aggregation and analysis(check each that applies): |
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Under §1915(c) of the Social Security Act and 42 CFR §441.302, the approval of an HCBS waiver requires that CMS determine that the State has made satisfactory assurances concerning the protection of participant health and welfare, financial accountability and other elements of waiver operations. Renewal of an existing waiver is contingent upon review by CMS and a finding by CMS that the assurances have been met. By completing the HCBS waiver application, the State specifies how it has designed the waiver’s critical processes, structures and operational features in order to meet these assurances.
CMS recognizes that a state’s waiver Quality Improvement Strategy may vary depending on the nature of the waiver target population, the services offered, and the waiver’s relationship to other public programs, and will extend beyond regulatory requirements. However, for the purpose of this application, the State is expected to have, at the minimum, systems in place to measure and improve its own performance in meeting six specific waiver assurances and requirements.
It may be more efficient and effective for a Quality Improvement Strategy to span multiple waivers and other long-term care services. CMS recognizes the value of this approach and will ask the state to identify other waiver programs and long-term care services that are addressed in the Quality Improvement Strategy.
The Quality Improvement Strategy that will be in effect during the period of the approved waiver is described throughout the waiver in the appendices corresponding to the statutory assurances and sub-assurances. Other documents cited must be available to CMS upon request through the Medicaid agency or the operating agency (if appropriate).
In the QIS discovery and remediation sections throughout the application (located in Appendices A, B, C, D, G, and I) , a state spells out:
In Appendix H of the application, a State describes (1) the system improvement activities followed in response to aggregated, analyzed discovery and remediation information collected on each of the assurances; (2) the correspondent roles/responsibilities of those conducting assessing and prioritizing improving system corrections and improvements; and (3) the processes the state will follow to continuously assess the effectiveness of the OIS and revise it as necessary and appropriate.
If the State's Quality Improvement Strategy is not fully developed at the time the waiver application is submitted, the state may provide a work plan to fully develop its Quality Improvement Strategy, including the specific tasks the State plans to undertake during the period the waiver is in effect, the major milestones associated with these tasks, and the entity (or entities) responsible for the completion of these tasks.
When the Quality Improvement Strategy spans more than one waiver and/or other types of long-term care services under the Medicaid State plan, specify the control numbers for the other waiver programs and/or identify the other long-term services that are addressed in the Quality Improvement Strategy. In instances when the QIS spans more than one waiver, the State must be able to stratify information that is related to each approved waiver program. Unless the State has requested and received approval from CMS for the consolidation of multiple waivers for the purpose of reporting, then the State must stratify information that is related to each approved waiver program, i.e., employ a representative sample for each waiver.
System Improvements
Responsible Party(check each that applies): | Frequency of Monitoring and Analysis(check each that applies): |
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System Design Changes
Financial Integrity.
Sub-assurance: The State provides evidence that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver and only for services rendered. (Performance measures in this sub-assurance include all Appendix I performance measures for waiver actions submitted before June 1, 2014.)
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Services are billed in accordance with the plan of care. % of claims submitted to and paid by MMIS will be monitored and reported by MRC using remittance advices. (Approved and paid MMIS claims/ Total service claims submitted)
Data Aggregation and Analysis:
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Performance Measure:
Services are billed in accordance with the plan of care. % of claims for services with the Fiscal Intermediary Service that are filed appropriately. (Approved claims filed with the Fiscal Intermediary Service/ Total number of claims filed with the Fiscal Intermediary Service)
Data Aggregation and Analysis:
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Sub-assurance: The state provides evidence that rates remain consistent with the approved rate methodology throughout the five year waiver cycle.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Services are coded and paid for in accordance with the reimbursement methodology. (number of services with rates derived from and consistent with rate regulations/ Number of services for which claims were submitted)
Data Aggregation and Analysis:
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Responsible Party(check each that applies): | Frequency of data aggregation and analysis(check each that applies): |
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Rate Determination Methods.
Flow of Billings.
Certifying Public Expenditures (select one):
Select at least one:
Billing Validation Process.
Billing and Claims Record Maintenance Requirement. Records documenting the audit trail of adjudicated claims (including supporting documentation) are maintained by the Medicaid agency, the operating agency (if applicable), and providers of waiver services for a minimum period of 3 years as required in 45 CFR §92.42.
Method of payments -- MMIS (select one):
Direct payment. In addition to providing that the Medicaid agency makes payments directly to providers of waiver services, payments for waiver services are made utilizing one or more of the following arrangements (select at least one):
Supplemental or Enhanced Payments. Section 1902(a)(30) requires that payments for services be consistent with efficiency, economy, and quality of care. Section 1903(a)(1) provides for Federal financial participation to States for expenditures for services under an approved State plan/waiver. Specify whether supplemental or enhanced payments are made. Select one:
Payments to State or Local Government Providers. Specify whether State or local government providers receive payment for the provision of waiver services.
Amount of Payment to State or Local Government Providers.
Specify whether any State or local government provider receives payments (including regular and any supplemental payments) that in the aggregate exceed its reasonable costs of providing waiver services and, if so, whether and how the State recoups the excess and returns the Federal share of the excess to CMS on the quarterly expenditure report. Select one:
Provider Retention of Payments. Section 1903(a)(1) provides that Federal matching funds are only available for expenditures made by states for services under the approved waiver. Select one:
Additional Payment Arrangements
Voluntary Reassignment of Payments to a Governmental Agency. Select one:
Organized Health Care Delivery System. Select one:
Contracts with MCOs, PIHPs or PAHPs. Select one:
State Level Source(s) of the Non-Federal Share of Computable Waiver Costs. Specify the State source or sources of the non-federal share of computable waiver costs. Select at least one:
Local Government or Other Source(s) of the Non-Federal Share of Computable Waiver Costs. Specify the source or sources of the non-federal share of computable waiver costs that are not from state sources. Select One:
Information Concerning Certain Sources of Funds. Indicate whether any of the funds listed in Items I-4-a or I-4-b that make up the non-federal share of computable waiver costs come from the following sources: (a) health care-related taxes or fees; (b) provider-related donations; and/or, (c) federal funds. Select one:
Services Furnished in Residential Settings. Select one:
Reimbursement for the Rent and Food Expenses of an Unrelated Live-In Personal Caregiver. Select one:
Co-Payment Requirements. Specify whether the State imposes a co-payment or similar charge upon waiver participants for waiver services. These charges are calculated per service and have the effect of reducing the total computable claim for federal financial participation. Select one:
Co-Pay Arrangement.
Specify the types of co-pay arrangements that are imposed on waiver participants (check each that applies):
Charges Associated with the Provision of Waiver Services (if any are checked, complete Items I-7-a-ii through I-7-a-iv):
Co-Payment Requirements.
Participants Subject to Co-pay Charges for Waiver Services.
Answers provided in Appendix I-7-a indicate that you do not need to complete this section.
Co-Payment Requirements.
Amount of Co-Pay Charges for Waiver Services.
Answers provided in Appendix I-7-a indicate that you do not need to complete this section.
Co-Payment Requirements.
Cumulative Maximum Charges.
Answers provided in Appendix I-7-a indicate that you do not need to complete this section.
Other State Requirement for Cost Sharing. Specify whether the State imposes a premium, enrollment fee or similar cost sharing on waiver participants. Select one:
Hospital, Nursing Facility
Col. 1 | Col. 2 | Col. 3 | Col. 4 | Col. 5 | Col. 6 | Col. 7 | Col. 8 |
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Year | Factor D | Factor D' | Total: D+D' | Factor G | Factor G' | Total: G+G' | Difference (Col 7 less Column4) |
1 | 16430.15 | 25851.16 | 77706.37 | 51855.21 | |||
2 | 24605.77 | 39267.79 | 120877.09 | 81609.30 | |||
3 | 28192.52 | 45048.80 | 138899.19 | 93850.39 | |||
4 | 30421.26 | 48742.72 | 150897.71 | 102154.99 | |||
5 | 32418.11 | 51903.14 | 160400.20 | 108497.06 |
Number Of Unduplicated Participants Served. Enter the total number of unduplicated participants from Item B-3-a who will be served each year that the waiver is in operation. When the waiver serves individuals under more than one level of care, specify the number of unduplicated participants for each level of care:
Waiver Year | Total Unduplicated Number of Participants (from Item B-3-a) | Distribution of Unduplicated Participants by Level of Care (if applicable) | |||
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Level of Care: | Level of Care: | ||||
Hospital | Nursing Facility | ||||
Year 1 | 125 | ||||
Year 2 | 240 | ||||
Year 3 | 350 | ||||
Year 4 | 464 | ||||
Year 5 | 579 |
Average Length of Stay.
Derivation of Estimates for Each Factor. Provide a narrative description for the derivation of the estimates of the following factors.
Component management for waiver services. If the service(s) below includes two or more discrete services that are reimbursed separately, or is a bundled service, each component of the service must be listed. Select “manage components” to add these components.
Waiver Services | ![]() |
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Home Health Aide | |
Homemaker | |
Personal Care | |
Prevocational Services | |
Respite | |
Supported Employment | |
Addiction Services | |
Adult Companion | |
Chore Service | |
Community Crisis Stabilization | |
Community Family Training | |
Community Psychiatric Support and Treatment (CPST) | |
Day Services | |
Home Accessibility Adaptations | |
Independent Living Supports | |
Individual Support and Community Habilitation | |
Medication Administration | |
Occupational Therapy | |
Peer Support | |
Physical Therapy | |
Shared Home Supports | |
Skilled Nursing | |
Specialized Medical Equipment | |
Speech Therapy | |
Supportive Home Care Aide | |
Transportation | |
Vehicle Modification |
Estimate of Factor D.
ii. Concurrent §1915(b)/§1915(c) Waivers, or other authorities utilizing capitated arrangements (i.e., 1915(a), 1932(a), Section 1937).
Waiver Service/ Component | Capi-tation | Unit | # Users | Avg. Units Per User | Avg. Cost/ Unit | Component Cost | Total Cost | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Home Health Aide Total: | 73749.00 | ||||||||||||||||||||||
Home Health Aide | 73749.00 | ||||||||||||||||||||||
Homemaker Total: | 66908.79 | ||||||||||||||||||||||
Homemaker | 66908.79 | ||||||||||||||||||||||
Personal Care Total: | 96279.30 | ||||||||||||||||||||||
Personal Care | 96279.30 | ||||||||||||||||||||||
Prevocational Services Total: | 113143.50 | ||||||||||||||||||||||
Prevocational Services - Per Diem | 44452.80 | ||||||||||||||||||||||
Prevocational Services - 15 min. | 68690.70 | ||||||||||||||||||||||
Respite Total: | 47892.25 | ||||||||||||||||||||||
Respite | 47892.25 | ||||||||||||||||||||||
Supported Employment Total: | 29737.44 | ||||||||||||||||||||||
Supported Employment | 29737.44 | ||||||||||||||||||||||
Addiction Services Total: | 6242.36 | ||||||||||||||||||||||
Addiction Services | 6242.36 | ||||||||||||||||||||||
Adult Companion Total: | 39951.60 | ||||||||||||||||||||||
Adult Companion | 39951.60 | ||||||||||||||||||||||
Chore Service Total: | 6152.96 | ||||||||||||||||||||||
Chore Service | 6152.96 | ||||||||||||||||||||||
Community Crisis Stabilization Total: | 7029.00 | ||||||||||||||||||||||
Community Crisis Stabilization | 7029.00 | ||||||||||||||||||||||
Community Family Training Total: | 8502.00 | ||||||||||||||||||||||
Community Family Training | 8502.00 | ||||||||||||||||||||||
Community Psychiatric Support and Treatment (CPST) Total: | 24992.55 | ||||||||||||||||||||||
Community Psychiatric Support and Treatment (CPST) | 24992.55 | ||||||||||||||||||||||
Day Services Total: | 324135.00 | ||||||||||||||||||||||
Day Services | 324135.00 | ||||||||||||||||||||||
Home Accessibility Adaptations Total: | 60000.00 | ||||||||||||||||||||||
Home Accessibility Adaptations | 60000.00 | ||||||||||||||||||||||
Independent Living Supports Total: | 416348.40 | ||||||||||||||||||||||
Independent Living Supports | 416348.40 | ||||||||||||||||||||||
Individual Support and Community Habilitation Total: | 123249.80 | ||||||||||||||||||||||
Individual Support and Community Habilitation | 123249.80 | ||||||||||||||||||||||
Medication Administration Total: | 22.81 | ||||||||||||||||||||||
Medication Administration | 22.81 | ||||||||||||||||||||||
Occupational Therapy Total: | 22214.40 | ||||||||||||||||||||||
Occupational Therapy | 22214.40 | ||||||||||||||||||||||
Peer Support Total: | 69388.80 | ||||||||||||||||||||||
Peer Support | 69388.80 | ||||||||||||||||||||||
Physical Therapy Total: | 50815.20 | ||||||||||||||||||||||
Physical Therapy | 50815.20 | ||||||||||||||||||||||
Shared Home Supports Total: | 167828.83 | ||||||||||||||||||||||
Shared Home Supports | 167828.83 | ||||||||||||||||||||||
Skilled Nursing Total: | 10438.56 | ||||||||||||||||||||||
Skilled Nursing | 10438.56 | ||||||||||||||||||||||
Specialized Medical Equipment Total: | 70560.65 | ||||||||||||||||||||||
Specialized Medical Equipment | 70560.65 | ||||||||||||||||||||||
Speech Therapy Total: | 22738.56 | ||||||||||||||||||||||
Speech Therapy | 22738.56 | ||||||||||||||||||||||
Supportive Home Care Aide Total: | 2877.30 | ||||||||||||||||||||||
Supportive Home Care Aide | 2877.30 | ||||||||||||||||||||||
Transportation Total: | 159236.00 | ||||||||||||||||||||||
Transportation | 159236.00 | ||||||||||||||||||||||
Vehicle Modification Total: | 33333.32 | ||||||||||||||||||||||
Vehicle Modification | 33333.32 | ||||||||||||||||||||||
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Estimate of Factor D.
ii. Concurrent §1915(b)/§1915(c) Waivers, or other authorities utilizing capitated arrangements (i.e., 1915(a), 1932(a), Section 1937).
Waiver Service/ Component | Capi-tation | Unit | # Users | Avg. Units Per User | Avg. Cost/ Unit | Component Cost | Total Cost | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Home Health Aide Total: | 221783.88 | ||||||||||||||||||||||
Home Health Aide | 221783.88 | ||||||||||||||||||||||
Homemaker Total: | 198313.50 | ||||||||||||||||||||||
Homemaker | 198313.50 | ||||||||||||||||||||||
Personal Care Total: | 286251.00 | ||||||||||||||||||||||
Personal Care | 286251.00 | ||||||||||||||||||||||
Prevocational Services Total: | 332053.86 | ||||||||||||||||||||||
Prevocational Services - Per Diem | 130356.00 | ||||||||||||||||||||||
Prevocational Services - 15 min. | 201697.86 | ||||||||||||||||||||||
Respite Total: | 135960.00 | ||||||||||||||||||||||
Respite | 135960.00 | ||||||||||||||||||||||
Supported Employment Total: | 87359.60 | ||||||||||||||||||||||
Supported Employment | 87359.60 | ||||||||||||||||||||||
Addiction Services Total: | 16687.10 | ||||||||||||||||||||||
Addiction Services | 16687.10 | ||||||||||||||||||||||
Adult Companion Total: | 118104.00 | ||||||||||||||||||||||
Adult Companion | 118104.00 | ||||||||||||||||||||||
Chore Service Total: | 18108.36 | ||||||||||||||||||||||
Chore Service | 18108.36 | ||||||||||||||||||||||
Community Crisis Stabilization Total: | 18795.89 | ||||||||||||||||||||||
Community Crisis Stabilization | 18795.89 | ||||||||||||||||||||||
Community Family Training Total: | 25426.56 | ||||||||||||||||||||||
Community Family Training | 25426.56 | ||||||||||||||||||||||
Community Psychiatric Support and Treatment (CPST) Total: | 66788.14 | ||||||||||||||||||||||
Community Psychiatric Support and Treatment (CPST) | 66788.14 | ||||||||||||||||||||||
Day Services Total: | 958500.00 | ||||||||||||||||||||||
Day Services | 958500.00 | ||||||||||||||||||||||
Home Accessibility Adaptations Total: | 108675.00 | ||||||||||||||||||||||
Home Accessibility Adaptations | 108675.00 | ||||||||||||||||||||||
Independent Living Supports Total: | 1252072.68 | ||||||||||||||||||||||
Independent Living Supports | 1252072.68 | ||||||||||||||||||||||
Individual Support and Community Habilitation Total: | 370968.00 | ||||||||||||||||||||||
Individual Support and Community Habilitation | 370968.00 | ||||||||||||||||||||||
Medication Administration Total: | 95.83 | ||||||||||||||||||||||
Medication Administration | 95.83 | ||||||||||||||||||||||
Occupational Therapy Total: | 63668.16 | ||||||||||||||||||||||
Occupational Therapy | 63668.16 | ||||||||||||||||||||||
Peer Support Total: | 207672.85 | ||||||||||||||||||||||
Peer Support | 207672.85 | ||||||||||||||||||||||
Physical Therapy Total: | 152690.40 | ||||||||||||||||||||||
Physical Therapy | 152690.40 | ||||||||||||||||||||||
Shared Home Supports Total: | 481949.76 | ||||||||||||||||||||||
Shared Home Supports | 481949.76 | ||||||||||||||||||||||
Skilled Nursing Total: | 32412.96 | ||||||||||||||||||||||
Skilled Nursing | 32412.96 | ||||||||||||||||||||||
Specialized Medical Equipment Total: | 141349.20 | ||||||||||||||||||||||
Specialized Medical Equipment | 141349.20 | ||||||||||||||||||||||
Speech Therapy Total: | 65171.52 | ||||||||||||||||||||||
Speech Therapy | 65171.52 | ||||||||||||||||||||||
Supportive Home Care Aide Total: | 8939.28 | ||||||||||||||||||||||
Supportive Home Care Aide | 8939.28 | ||||||||||||||||||||||
Transportation Total: | 475211.52 | ||||||||||||||||||||||
Transportation | 475211.52 | ||||||||||||||||||||||
Vehicle Modification Total: | 60375.00 | ||||||||||||||||||||||
Vehicle Modification | 60375.00 | ||||||||||||||||||||||
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Estimate of Factor D.
ii. Concurrent §1915(b)/§1915(c) Waivers, or other authorities utilizing capitated arrangements (i.e., 1915(a), 1932(a), Section 1937).
Waiver Service/ Component | Capi-tation | Unit | # Users | Avg. Units Per User | Avg. Cost/ Unit | Component Cost | Total Cost | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Home Health Aide Total: | 368879.70 | ||||||||||||||||||||||
Home Health Aide | 368879.70 | ||||||||||||||||||||||
Homemaker Total: | 331257.15 | ||||||||||||||||||||||
Homemaker | 331257.15 | ||||||||||||||||||||||
Personal Care Total: | 481662.72 | ||||||||||||||||||||||
Personal Care | 481662.72 | ||||||||||||||||||||||
Prevocational Services Total: | 561287.00 | ||||||||||||||||||||||
Prevocational Services - Per Diem | 220460.00 | ||||||||||||||||||||||
Prevocational Services - 15 min. | 340827.00 | ||||||||||||||||||||||
Respite Total: | 225733.20 | ||||||||||||||||||||||
Respite | 225733.20 | ||||||||||||||||||||||
Supported Employment Total: | 147637.00 | ||||||||||||||||||||||
Supported Employment | 147637.00 | ||||||||||||||||||||||
Addiction Services Total: | 28722.66 | ||||||||||||||||||||||
Addiction Services | 28722.66 | ||||||||||||||||||||||
Adult Companion Total: | 199780.56 | ||||||||||||||||||||||
Adult Companion | 199780.56 | ||||||||||||||||||||||
Chore Service Total: | 30411.40 | ||||||||||||||||||||||
Chore Service | 30411.40 | ||||||||||||||||||||||
Community Crisis Stabilization Total: | 32335.91 | ||||||||||||||||||||||
Community Crisis Stabilization | 32335.91 | ||||||||||||||||||||||
Community Family Training Total: | 42551.60 | ||||||||||||||||||||||
Community Family Training | 42551.60 | ||||||||||||||||||||||
Community Psychiatric Support and Treatment (CPST) Total: | 114948.59 | ||||||||||||||||||||||
Community Psychiatric Support and Treatment (CPST) | 114948.59 | ||||||||||||||||||||||
Day Services Total: | 1601090.75 | ||||||||||||||||||||||
Day Services | 1601090.75 | ||||||||||||||||||||||
Home Accessibility Adaptations Total: | 176752.18 | ||||||||||||||||||||||
Home Accessibility Adaptations | 176752.18 | ||||||||||||||||||||||
Independent Living Supports Total: | 2083596.48 | ||||||||||||||||||||||
Independent Living Supports | 2083596.48 | ||||||||||||||||||||||
Individual Support and Community Habilitation Total: | 625092.16 | ||||||||||||||||||||||
Individual Support and Community Habilitation | 625092.16 | ||||||||||||||||||||||
Medication Administration Total: | 187.64 | ||||||||||||||||||||||
Medication Administration | 187.64 | ||||||||||||||||||||||
Occupational Therapy Total: | 106778.00 | ||||||||||||||||||||||
Occupational Therapy | 106778.00 | ||||||||||||||||||||||
Peer Support Total: | 346772.16 | ||||||||||||||||||||||
Peer Support | 346772.16 | ||||||||||||||||||||||
Physical Therapy Total: | 257523.20 | ||||||||||||||||||||||
Physical Therapy | 257523.20 | ||||||||||||||||||||||
Shared Home Supports Total: | 807662.10 | ||||||||||||||||||||||
Shared Home Supports | 807662.10 | ||||||||||||||||||||||
Skilled Nursing Total: | 55915.20 | ||||||||||||||||||||||
Skilled Nursing | 55915.20 | ||||||||||||||||||||||
Specialized Medical Equipment Total: | 214567.76 | ||||||||||||||||||||||
Specialized Medical Equipment | 214567.76 | ||||||||||||||||||||||
Speech Therapy Total: | 109298.00 | ||||||||||||||||||||||
Speech Therapy | 109298.00 | ||||||||||||||||||||||
Supportive Home Care Aide Total: | 20544.20 | ||||||||||||||||||||||
Supportive Home Care Aide | 20544.20 | ||||||||||||||||||||||
Transportation Total: | 798200.20 | ||||||||||||||||||||||
Transportation | 798200.20 | ||||||||||||||||||||||
Vehicle Modification Total: | 98195.68 | ||||||||||||||||||||||
Vehicle Modification | 98195.68 | ||||||||||||||||||||||
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Estimate of Factor D.
ii. Concurrent §1915(b)/§1915(c) Waivers, or other authorities utilizing capitated arrangements (i.e., 1915(a), 1932(a), Section 1937).
Waiver Service/ Component | Capi-tation | Unit | # Users | Avg. Units Per User | Avg. Cost/ Unit | Component Cost | Total Cost | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Home Health Aide Total: | 534526.72 | ||||||||||||||||||||||
Home Health Aide | 534526.72 | ||||||||||||||||||||||
Homemaker Total: | 476716.50 | ||||||||||||||||||||||
Homemaker | 476716.50 | ||||||||||||||||||||||
Personal Care Total: | 693581.06 | ||||||||||||||||||||||
Personal Care | 693581.06 | ||||||||||||||||||||||
Prevocational Services Total: | 781015.04 | ||||||||||||||||||||||
Prevocational Services - Per Diem | 306673.92 | ||||||||||||||||||||||
Prevocational Services - 15 min. | 474341.12 | ||||||||||||||||||||||
Respite Total: | 310398.66 | ||||||||||||||||||||||
Respite | 310398.66 | ||||||||||||||||||||||
Supported Employment Total: | 205287.68 | ||||||||||||||||||||||
Supported Employment | 205287.68 | ||||||||||||||||||||||
Addiction Services Total: | 44590.49 | ||||||||||||||||||||||
Addiction Services | 44590.49 | ||||||||||||||||||||||
Adult Companion Total: | 286541.32 | ||||||||||||||||||||||
Adult Companion | 286541.32 | ||||||||||||||||||||||
Chore Service Total: | 43736.00 | ||||||||||||||||||||||
Chore Service | 43736.00 | ||||||||||||||||||||||
Community Crisis Stabilization Total: | 49883.37 | ||||||||||||||||||||||
Community Crisis Stabilization | 49883.37 | ||||||||||||||||||||||
Community Family Training Total: | 61459.98 | ||||||||||||||||||||||
Community Family Training | 61459.98 | ||||||||||||||||||||||
Community Psychiatric Support and Treatment (CPST) Total: | 177708.94 | ||||||||||||||||||||||
Community Psychiatric Support and Treatment (CPST) | 177708.94 | ||||||||||||||||||||||
Day Services Total: | 2329261.44 | ||||||||||||||||||||||
Day Services | 2329261.44 | ||||||||||||||||||||||
Home Accessibility Adaptations Total: | 232830.78 | ||||||||||||||||||||||
Home Accessibility Adaptations | 232830.78 | ||||||||||||||||||||||
Independent Living Supports Total: | 2991210.24 | ||||||||||||||||||||||
Independent Living Supports | 2991210.24 | ||||||||||||||||||||||
Individual Support and Community Habilitation Total: | 895510.72 | ||||||||||||||||||||||
Individual Support and Community Habilitation | 895510.72 | ||||||||||||||||||||||
Medication Administration Total: | 269.39 | ||||||||||||||||||||||
Medication Administration | 269.39 | ||||||||||||||||||||||
Occupational Therapy Total: | 152512.08 | ||||||||||||||||||||||
Occupational Therapy | 152512.08 | ||||||||||||||||||||||
Peer Support Total: | 498253.84 | ||||||||||||||||||||||
Peer Support | 498253.84 | ||||||||||||||||||||||
Physical Therapy Total: | 368907.84 | ||||||||||||||||||||||
Physical Therapy | 368907.84 | ||||||||||||||||||||||
Shared Home Supports Total: | 1153139.04 | ||||||||||||||||||||||
Shared Home Supports | 1153139.04 | ||||||||||||||||||||||
Skilled Nursing Total: | 77647.08 | ||||||||||||||||||||||
Skilled Nursing | 77647.08 | ||||||||||||||||||||||
Specialized Medical Equipment Total: | 292738.76 | ||||||||||||||||||||||
Specialized Medical Equipment | 292738.76 | ||||||||||||||||||||||
Speech Therapy Total: | 156105.60 | ||||||||||||||||||||||
Speech Therapy | 156105.60 | ||||||||||||||||||||||
Supportive Home Care Aide Total: | 27922.50 | ||||||||||||||||||||||
Supportive Home Care Aide | 27922.50 | ||||||||||||||||||||||
Transportation Total: | 1144357.50 | ||||||||||||||||||||||
Transportation | 1144357.50 | ||||||||||||||||||||||
Vehicle Modification Total: | 129350.48 | ||||||||||||||||||||||
Vehicle Modification | 129350.48 | ||||||||||||||||||||||
|
Estimate of Factor D.
ii. Concurrent §1915(b)/§1915(c) Waivers, or other authorities utilizing capitated arrangements (i.e., 1915(a), 1932(a), Section 1937).
Waiver Service/ Component | Capi-tation | Unit | # Users | Avg. Units Per User | Avg. Cost/ Unit | Component Cost | Total Cost | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Home Health Aide Total: | 700350.00 | ||||||||||||||||||||||
Home Health Aide | 700350.00 | ||||||||||||||||||||||
Homemaker Total: | 632174.22 | ||||||||||||||||||||||
Homemaker | 632174.22 | ||||||||||||||||||||||
Personal Care Total: | 918815.04 | ||||||||||||||||||||||
Personal Care | 918815.04 | ||||||||||||||||||||||
Prevocational Services Total: | 1067189.82 | ||||||||||||||||||||||
Prevocational Services - Per Diem | 421191.36 | ||||||||||||||||||||||
Prevocational Services - 15 min. | 645998.46 | ||||||||||||||||||||||
Respite Total: | 437143.68 | ||||||||||||||||||||||
Respite | 437143.68 | ||||||||||||||||||||||
Supported Employment Total: | 279418.28 | ||||||||||||||||||||||
Supported Employment | 279418.28 | ||||||||||||||||||||||
Addiction Services Total: | 58380.32 | ||||||||||||||||||||||
Addiction Services | 58380.32 | ||||||||||||||||||||||
Adult Companion Total: | 383212.08 | ||||||||||||||||||||||
Adult Companion | 383212.08 | ||||||||||||||||||||||
Chore Service Total: | 57642.72 | ||||||||||||||||||||||
Chore Service | 57642.72 | ||||||||||||||||||||||
Community Crisis Stabilization Total: | 65379.31 | ||||||||||||||||||||||
Community Crisis Stabilization | 65379.31 | ||||||||||||||||||||||
Community Family Training Total: | 81810.16 | ||||||||||||||||||||||
Community Family Training | 81810.16 | ||||||||||||||||||||||
Community Psychiatric Support and Treatment (CPST) Total: | 232847.59 | ||||||||||||||||||||||
Community Psychiatric Support and Treatment (CPST) | 232847.59 | ||||||||||||||||||||||
Day Services Total: | 3081888.00 | ||||||||||||||||||||||
Day Services | 3081888.00 | ||||||||||||||||||||||
Home Accessibility Adaptations Total: | 292618.45 | ||||||||||||||||||||||
Home Accessibility Adaptations | 292618.45 | ||||||||||||||||||||||
Independent Living Supports Total: | 3981782.88 | ||||||||||||||||||||||
Independent Living Supports | 3981782.88 | ||||||||||||||||||||||
Individual Support and Community Habilitation Total: | 1189446.60 | ||||||||||||||||||||||
Individual Support and Community Habilitation | 1189446.60 | ||||||||||||||||||||||
Medication Administration Total: | 359.56 | ||||||||||||||||||||||
Medication Administration | 359.56 | ||||||||||||||||||||||
Occupational Therapy Total: | 203759.80 | ||||||||||||||||||||||
Occupational Therapy | 203759.80 | ||||||||||||||||||||||
Peer Support Total: | 661637.70 | ||||||||||||||||||||||
Peer Support | 661637.70 | ||||||||||||||||||||||
Physical Therapy Total: | 488636.95 | ||||||||||||||||||||||
Physical Therapy | 488636.95 | ||||||||||||||||||||||
Shared Home Supports Total: | 1545444.80 | ||||||||||||||||||||||
Shared Home Supports | 1545444.80 | ||||||||||||||||||||||
Skilled Nursing Total: | 103737.93 | ||||||||||||||||||||||
Skilled Nursing | 103737.93 | ||||||||||||||||||||||
Specialized Medical Equipment Total: | 378731.30 | ||||||||||||||||||||||
Specialized Medical Equipment | 378731.30 | ||||||||||||||||||||||
Speech Therapy Total: | 208573.22 | ||||||||||||||||||||||
Speech Therapy | 208573.22 | ||||||||||||||||||||||
Supportive Home Care Aide Total: | 35640.00 | ||||||||||||||||||||||
Supportive Home Care Aide | 35640.00 | ||||||||||||||||||||||
Transportation Total: | 1520896.50 | ||||||||||||||||||||||
Transportation | 1520896.50 | ||||||||||||||||||||||
Vehicle Modification Total: | 162565.90 | ||||||||||||||||||||||
Vehicle Modification | 162565.90 | ||||||||||||||||||||||
|