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 waiver’s 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.
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:
Number and percent of assigned quality assurance reviews completed quarterly by the contracted agencies. Numerator = number of quarterly quality assurance reviews completed by contracted agencies; Denominator = number of quarterly quality assurance reviews assigned to contracted agencies.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of setting assessments completed where the provider was either compliant or progressing toward a plan for compliance with HCBS setting requirements. Numerator = Number of setting assessments completed where the provider was either compliant or progressing toward a plan for compliance with HCBS setting requirements; Denominator = Number of setting assessments completed.
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 |
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 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.
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).
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:
Regular Post-Eligibility Treatment of Income: SSI State - 2014 through 2018.
Answers provided in Appendix B-5-a indicate the selections in B-5-b also apply to B-5-e.
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).
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:
Number and percent of new waiver eligible applicants reviewed for whom nursing facility Level of Care (LOC) was determined prior to the receipt of services. Numerator = number of new waiver eligible applicants reviewed for whom nursing facility LOC was determined prior to receipt of services; Denominator = number of new waiver eligible applicants reviewed.
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.
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:
Number and percent of initial and annual Level of Care (LOC) determinations reviewed in which LOC criteria were accurately applied. Numerator = number of initial and annual LOC determinations reviewed in which LOC criteria were accurately applied; Denominator = number of initial and annual LOC determinations reviewed.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of participants for whom initial or annual Level of Care (LOC) is determined using the appropriate instrument. Numerator = number of participants for whom LOC is determined using the appropriate instrument; Denominator = number of participants reviewed for whom LOC is determined.
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 | Adult Day Health Services | ||
Statutory Service | Chore Services | ||
Statutory Service | Respite Services | ||
Other Service | Assisted Living Service | ||
Other Service | Assistive Technology Supports and Home Modifications | ||
Other Service | Extra Care for Children with Disabilities | ||
Other Service | Home Again Services | ||
Other Service | Home Delivered Meals | ||
Other Service | Independent Skills Building | ||
Other Service | Nutrition Services | ||
Other Service | Personal Emergency Response System (PERS) | ||
Other Service | Transportation Services |
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:
Complete this part for a renewal application or a new waiver that replaces an
existing waiver. Select one
:
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:
Complete this part for a renewal application or a new waiver that replaces an
existing waiver. Select one
:
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:
Complete this part for a renewal application or a new waiver that replaces an
existing waiver. Select one
:
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:
Complete this part for a renewal application or a new waiver that replaces an
existing waiver. Select one
:
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:
Complete this part for a renewal application or a new waiver that replaces an
existing waiver. Select one
:
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:
Complete this part for a renewal application or a new waiver that replaces an
existing waiver. Select one
:
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:
Complete this part for a renewal application or a new waiver that replaces an
existing waiver. Select one
:
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:
Complete this part for a renewal application or a new waiver that replaces an
existing waiver. Select one
:
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:
Complete this part for a renewal application or a new waiver that replaces an
existing waiver. Select one
:
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:
Complete this part for a renewal application or a new waiver that replaces an
existing waiver. Select one
:
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:
Complete this part for a renewal application or a new waiver that replaces an
existing waiver. Select one
:
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:
Complete this part for a renewal application or a new waiver that replaces an
existing waiver. Select one
:
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:
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:
Number and percent of enrolled non-licensed, certified providers reviewed that met provider standards at annual review. Numerator = number of enrolled non-licensed, certified providers reviewed that met provider standards at annual review; Denominator = number of enrolled non-licensed, certified providers reviewed that have had an annual review.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of enrolled licensed, certified providers reviewed that initially met provider standards prior to furnishing waiver services. Numerator = number of enrolled licensed, certified providers reviewed that initially met provider standards; Denominator = number of initial enrolled licensed, certified providers reviewed.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of enrolled licensed, certified providers reviewed that met provider standards at annual review. Numerator = number of enrolled licensed, certified providers reviewed that met provider standards at annual review; Denominator = number of enrolled licensed, certified providers reviewed that have had an annual review.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of enrolled non-licensed, certified providers reviewed that initially met provider standards prior to furnishing waiver services. Numerator = number of enrolled non-licensed, certified providers reviewed that initially met provider standards; Denominator = number of initial enrolled non-licensed, certified providers reviewed.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of enrolled non-licensed, certified providers reviewed that have had an annual review. Numerator = number of enrolled non-licensed, certified providers reviewed that have had annual review; Denominator = number of enrolled non-licensed, certified providers reviewed.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of enrolled licensed, certified providers reviewed that have had an annual review. Numerator = number of enrolled licensed, certified providers reviewed that have had annual review; Denominator = number of enrolled licensed, certified providers reviewed.
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.
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:
Number and percent of all newly hired Service Coordination (SC) and Resource Development (RD) staff enrolled in web-based training who successfully completed the training. Numerator = number of newly hired SC and RD staff enrolled in web-based training who successfully completed the training; Denominator = number of newly hired SC and RD staff enrolled in web-based training.
Data Aggregation and Analysis:
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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:
Number and percent of participants reviewed for whom all assessed personal goals have been addressed in the Plan of Services and Supports (POSS). Numerator = number of participants reviewed for whom all assessed personal goals have been addressed in the POSS; Denominator = number of participants reviewed.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of participants reviewed for whom all assessed needs (including health and safety risk factors) have been addressed in the Plan of Services and Supports (POSS). Numerator = number of participants reviewed for whom all assessed needs have been addressed in the POSS; Denominator = number of participants 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.
Sub-assurance: Service plans are updated/revised at least annually or when warranted by changes in the waiver participant’s 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:
Number and percent of participants reviewed whose Plans of Services and Supports (POSS) were revised, as needed, to address changing needs. Numerator = number of participants reviewed whose POSS were revised, as needed, to address changing needs; Denominator = number of participants reviewed.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of participants reviewed whose Plans of Services and Supports (POSS) were reviewed and revised on or before the annual review date. Numerator = number of participants reviewed whose POSS were reviewed and revised on or before the annual review date. Denominator = number of participants reviewed.
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:
# and % of participants reviewed for whom there is monthly monitoring narrative evidence that waiver services were delivered in accordance with the Plan of Services and Supports (POSS). Numerator: # of participants reviewed for whom there is monthly monitoring narrative evidence that waiver services were delivered in accordance with the POSS. Denominator: # of participants reviewed.
Data Aggregation and Analysis:
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Sub-assurance: Participants are afforded choice: 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:
Number and percent of participants reviewed whose file indicated participants chose among providers. Numerator = number of participants reviewed whose files indicated participants chose among providers; Denominator = number of participants reviewed.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of participants reviewed whose file indicated participants chose among types of services. Numerator = number of participants reviewed whose files indicated participants chose among types of services; Denominator = number of participants reviewed.
Data Aggregation and Analysis:
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Performance Measure:
# and % of participants reviewed who have been informed about provision of services and provision of Services Coordination (SC) when served by SC Agencies that also provide waiver services. Numerator=# of participants reviewed who have been informed about provision of services and provision of SC when served by SC Agencies that also provide waiver services. Denominator= # of participants reviewed.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of participants reviewed whose file is free of evidence of conflict of interest between the provision of services and the provision of Services Coordination. Numerator = Number of participants reviewed whose file is free of evidence of conflict of interest between the provision of services and the provision of Services Coordination. Denominator = Number of participants reviewed.
Data Aggregation and Analysis:
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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):
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
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:
Number and percent of participants' death reviews conducted which did not require additional follow up/remediation. Numerator = number of participants' death reviews conducted which did not require additional follow up/remediation; Denominator = number of participants' death reviews conducted.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of participants reviewed who received information/education about how to report abuse, neglect exploitation and other critical incidents as specified in the approved waiver. Numerator = number of participants reviewed who received information/education; Denominator = number of participants 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:
Number and percent of HCBS Waiver Incident reports completed with appropriate waiver resolution activity. Numerator = number of HCBS Waiver Incident reports completed with appropriate waiver resolution activity; Denominator = number of HCBS Waiver Incident reports.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of incident reports submitted by Service Coordination Agencies for substantiated Adult and Child Protective Services (APS/CPS) intakes. Numerator = Number of incident reports submitted by the Service Coordination agencies for substantiated APS/CPS intakes. Denominator = Number of substantiated APS/CPS intakes.
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:
Number and percent of participants reviewed for whom the file contains no evidence of the use of restrictive measures, including restraints and seclusion. Numerator = Number of participants reviewed for whom the file contains no evidence of the use of restrictive measures, including restraints and seclusion. Denominator = Number of participants reviewed.
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:
Number and percent of participants reviewed whose health care status was assessed at the initial review or annual assessment. Numerator = Number of participants reviewed whose health care status was assessed at the initial review or annual assessment. Denominator = Number of participants reviewed.
Data Aggregation and Analysis:
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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:
Number and percent of paid claims reviewed that were coded in accordance with the reimbursement methodology specified in the approved waiver. Numerator: Number of paid claims reviewed that were coded in accordance with the reimbursement methodology specified in the approved waiver. Denominator: Number of paid claims reviewed.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of paid claims reviewed which were in accordance with the reimbursement methodology specified in the approved waiver. Numerator = Number of paid claims reviewed which were in accordance with the reimbursement methodology specified in the approved waiver. Denominator = Number of paid claims reviewed.
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:
Number and percent of providers reviewed for whom rate changes were consistent with the approved rate methodology. Numerator = Number and percent of providers reviewed for whom rate changes were consistent with the approved rate methodology. Denominator = Number of providers reviewed.
Data Aggregation and Analysis:
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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:
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 | 12471.03 | 20097.03 | 38937.00 | 18839.97 | |||
2 | 12715.29 | 20493.29 | 39716.00 | 19222.71 | |||
3 | 12965.71 | 20899.71 | 40511.00 | 19611.29 | |||
4 | 13219.98 | 21312.98 | 41321.00 | 20008.02 | |||
5 | 13480.45 | 21734.45 | 42147.00 | 20412.55 |
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: | |||||
Nursing Facility | |||||
Year 1 | 6100 | ||||
Year 2 | 6200 | ||||
Year 3 | 6300 | ||||
Year 4 | 6400 | ||||
Year 5 | 6500 |
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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Adult Day Health Services | |
Chore Services | |
Respite Services | |
Assisted Living Service | |
Assistive Technology Supports and Home Modifications | |
Extra Care for Children with Disabilities | |
Home Again Services | |
Home Delivered Meals | |
Independent Skills Building | |
Nutrition Services | |
Personal Emergency Response System (PERS) | |
Transportation Services |
Estimate of Factor D.
i. Non-Concurrent Waiver.
Waiver Service/ Component | Unit | # Users | Avg. Units Per User | Avg. Cost/ Unit | Component Cost | Total Cost | ||||||||
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Adult Day Health Services Total: | 514323.10 | |||||||||||||
Adult Day Health Services | 514323.10 | |||||||||||||
Chore Services Total: | 28589284.08 | |||||||||||||
Chore Services Day | 9023842.08 | |||||||||||||
Chore Services Hourly | 19565442.00 | |||||||||||||
Respite Services Total: | 1144803.55 | |||||||||||||
Respite Care Day | 417772.30 | |||||||||||||
Respite Care Hourly | 727031.25 | |||||||||||||
Assisted Living Service Total: | 37225541.84 | |||||||||||||
Assisted Living Rural / Single | 17005006.08 | |||||||||||||
Assisted Living Rural / Multiple | 614028.24 | |||||||||||||
Assisted Living Urban / Single | 18941130.56 | |||||||||||||
Assisted Living Urban / Multiple | 665376.96 | |||||||||||||
Assistive Technology Supports and Home Modifications Total: | 1987777.68 | |||||||||||||
Assistive Technology Supports | 348039.76 | |||||||||||||
Home Modifications | 1639737.92 | |||||||||||||
Extra Care for Children with Disabilities Total: | 5304441.00 | |||||||||||||
Child / Youth Care Day | 1854754.50 | |||||||||||||
Child / Youth Care Hourly | 3449686.50 | |||||||||||||
Home Again Services Total: | 22500.00 | |||||||||||||
Home Again Services | 22500.00 | |||||||||||||
Home Delivered Meals Total: | 591362.20 | |||||||||||||
Home Delivered Meals | 591362.20 | |||||||||||||
Independent Skills Building Total: | 50323.00 | |||||||||||||
Independent Skills Building | 50323.00 | |||||||||||||
Nutrition Services Total: | 23529.00 | |||||||||||||
Nutrition Services | 23529.00 | |||||||||||||
Personal Emergency Response System (PERS) Total: | 475902.72 | |||||||||||||
Personal Emergency Response System (PERS) | 475902.72 | |||||||||||||
Transportation Services Total: | 143521.00 | |||||||||||||
Non-Medical Transportation By One Way Trip | 57380.40 | |||||||||||||
Non-Medical Transportation By Mile | 42148.60 | |||||||||||||
Non-Medical Transportation By Hour | 43992.00 | |||||||||||||
|
Estimate of Factor D.
i. Non-Concurrent Waiver.
Waiver Service/ Component | Unit | # Users | Avg. Units Per User | Avg. Cost/ Unit | Component Cost | Total Cost | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Adult Day Health Services Total: | 530801.46 | |||||||||||||
Adult Day Health Services | 530801.46 | |||||||||||||
Chore Services Total: | 29630389.24 | |||||||||||||
Chore Services Day | 9357213.60 | |||||||||||||
Chore Services Hourly | 20273175.64 | |||||||||||||
Respite Services Total: | 1186459.34 | |||||||||||||
Respite Care Day | 432887.84 | |||||||||||||
Respite Care Hourly | 753571.50 | |||||||||||||
Assisted Living Service Total: | 38571378.88 | |||||||||||||
Assisted Living Rural / Single | 17618464.48 | |||||||||||||
Assisted Living Rural / Multiple | 636252.16 | |||||||||||||
Assisted Living Urban / Single | 19626072.48 | |||||||||||||
Assisted Living Urban / Multiple | 690589.76 | |||||||||||||
Assistive Technology Supports and Home Modifications Total: | 2060311.10 | |||||||||||||
Assistive Technology Supports | 359797.50 | |||||||||||||
Home Modifications | 1700513.60 | |||||||||||||
Extra Care for Children with Disabilities Total: | 5502533.40 | |||||||||||||
Child / Youth Care Day | 1924673.40 | |||||||||||||
Child / Youth Care Hourly | 3577860.00 | |||||||||||||
Home Again Services Total: | 22500.00 | |||||||||||||
Home Again Services | 22500.00 | |||||||||||||
Home Delivered Meals Total: | 612674.70 | |||||||||||||
Home Delivered Meals | 612674.70 | |||||||||||||
Independent Skills Building Total: | 51318.40 | |||||||||||||
Independent Skills Building | 51318.40 | |||||||||||||
Nutrition Services Total: | 24480.00 | |||||||||||||
Nutrition Services | 24480.00 | |||||||||||||
Personal Emergency Response System (PERS) Total: | 493138.80 | |||||||||||||
Personal Emergency Response System (PERS) | 493138.80 | |||||||||||||
Transportation Services Total: | 148798.70 | |||||||||||||
Non-Medical Transportation By One Way Trip | 59327.10 | |||||||||||||
Non-Medical Transportation By Mile | 43636.40 | |||||||||||||
Non-Medical Transportation By Hour | 45835.20 | |||||||||||||
|
Estimate of Factor D.
i. Non-Concurrent Waiver.
Waiver Service/ Component | Unit | # Users | Avg. Units Per User | Avg. Cost/ Unit | Component Cost | Total Cost | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Adult Day Health Services Total: | 547691.10 | |||||||||||||
Adult Day Health Services | 547691.10 | |||||||||||||
Chore Services Total: | 30710368.80 | |||||||||||||
Chore Services Day | 9701090.40 | |||||||||||||
Chore Services Hourly | 21009278.40 | |||||||||||||
Respite Services Total: | 1229040.84 | |||||||||||||
Respite Care Day | 448461.09 | |||||||||||||
Respite Care Hourly | 780579.75 | |||||||||||||
Assisted Living Service Total: | 39956159.84 | |||||||||||||
Assisted Living Rural / Single | 18249659.12 | |||||||||||||
Assisted Living Rural / Multiple | 659115.60 | |||||||||||||
Assisted Living Urban / Single | 20330837.20 | |||||||||||||
Assisted Living Urban / Multiple | 716547.92 | |||||||||||||
Assistive Technology Supports and Home Modifications Total: | 2134951.12 | |||||||||||||
Assistive Technology Supports | 371886.24 | |||||||||||||
Home Modifications | 1763064.88 | |||||||||||||
Extra Care for Children with Disabilities Total: | 5705022.54 | |||||||||||||
Child / Youth Care Day | 1996672.44 | |||||||||||||
Child / Youth Care Hourly | 3708350.10 | |||||||||||||
Home Again Services Total: | 22500.00 | |||||||||||||
Home Again Services | 22500.00 | |||||||||||||
Home Delivered Meals Total: | 635430.25 | |||||||||||||
Home Delivered Meals | 635430.25 | |||||||||||||
Independent Skills Building Total: | 52369.10 | |||||||||||||
Independent Skills Building | 52369.10 | |||||||||||||
Nutrition Services Total: | 25459.20 | |||||||||||||
Nutrition Services | 25459.20 | |||||||||||||
Personal Emergency Response System (PERS) Total: | 510818.04 | |||||||||||||
Personal Emergency Response System (PERS) | 510818.04 | |||||||||||||
Transportation Services Total: | 154171.50 | |||||||||||||
Non-Medical Transportation By One Way Trip | 61305.30 | |||||||||||||
Non-Medical Transportation By Mile | 45150.00 | |||||||||||||
Non-Medical Transportation By Hour | 47716.20 | |||||||||||||
|
Estimate of Factor D.
i. Non-Concurrent Waiver.
Waiver Service/ Component | Unit | # Users | Avg. Units Per User | Avg. Cost/ Unit | Component Cost | Total Cost | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Adult Day Health Services Total: | 565083.20 | |||||||||||||
Adult Day Health Services | 565083.20 | |||||||||||||
Chore Services Total: | 31812495.32 | |||||||||||||
Chore Services Day | 10054163.04 | |||||||||||||
Chore Services Hourly | 21758332.28 | |||||||||||||
Respite Services Total: | 1272556.96 | |||||||||||||
Respite Care Day | 464500.96 | |||||||||||||
Respite Care Hourly | 808056.00 | |||||||||||||
Assisted Living Service Total: | 41380910.08 | |||||||||||||
Assisted Living Rural / Single | 18899017.92 | |||||||||||||
Assisted Living Rural / Multiple | 682640.64 | |||||||||||||
Assisted Living Urban / Single | 21055985.92 | |||||||||||||
Assisted Living Urban / Multiple | 743265.60 | |||||||||||||
Assistive Technology Supports and Home Modifications Total: | 2211750.70 | |||||||||||||
Assistive Technology Supports | 384314.70 | |||||||||||||
Home Modifications | 1827436.00 | |||||||||||||
Extra Care for Children with Disabilities Total: | 5915271.18 | |||||||||||||
Child / Youth Care Day | 2070791.58 | |||||||||||||
Child / Youth Care Hourly | 3844479.60 | |||||||||||||
Home Again Services Total: | 22500.00 | |||||||||||||
Home Again Services | 22500.00 | |||||||||||||
Home Delivered Meals Total: | 658595.00 | |||||||||||||
Home Delivered Meals | 658595.00 | |||||||||||||
Independent Skills Building Total: | 53419.80 | |||||||||||||
Independent Skills Building | 53419.80 | |||||||||||||
Nutrition Services Total: | 26467.14 | |||||||||||||
Nutrition Services | 26467.14 | |||||||||||||
Personal Emergency Response System (PERS) Total: | 529089.84 | |||||||||||||
Personal Emergency Response System (PERS) | 529089.84 | |||||||||||||
Transportation Services Total: | 159763.15 | |||||||||||||
Non-Medical Transportation By One Way Trip | 63393.75 | |||||||||||||
Non-Medical Transportation By Mile | 46689.40 | |||||||||||||
Non-Medical Transportation By Hour | 49680.00 | |||||||||||||
|
Estimate of Factor D.
i. Non-Concurrent Waiver.
Waiver Service/ Component | Unit | # Users | Avg. Units Per User | Avg. Cost/ Unit | Component Cost | Total Cost | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Adult Day Health Services Total: | 582900.16 | |||||||||||||
Adult Day Health Services | 582900.16 | |||||||||||||
Chore Services Total: | 32954879.36 | |||||||||||||
Chore Services Day | 10418127.84 | |||||||||||||
Chore Services Hourly | 22536751.52 | |||||||||||||
Respite Services Total: | 1317674.36 | |||||||||||||
Respite Care Day | 481016.36 | |||||||||||||
Respite Care Hourly | 836658.00 | |||||||||||||
Assisted Living Service Total: | 42846684.48 | |||||||||||||
Assisted Living Rural / Single | 19567083.12 | |||||||||||||
Assisted Living Rural / Multiple | 706844.64 | |||||||||||||
Assisted Living Urban / Single | 21801990.00 | |||||||||||||
Assisted Living Urban / Multiple | 770766.72 | |||||||||||||
Assistive Technology Supports and Home Modifications Total: | 2290769.42 | |||||||||||||
Assistive Technology Supports | 397091.76 | |||||||||||||
Home Modifications | 1893677.66 | |||||||||||||
Extra Care for Children with Disabilities Total: | 6130101.78 | |||||||||||||
Child / Youth Care Day | 2147070.78 | |||||||||||||
Child / Youth Care Hourly | 3983031.00 | |||||||||||||
Home Again Services Total: | 22500.00 | |||||||||||||
Home Again Services | 22500.00 | |||||||||||||
Home Delivered Meals Total: | 682168.95 | |||||||||||||
Home Delivered Meals | 682168.95 | |||||||||||||
Independent Skills Building Total: | 54470.50 | |||||||||||||
Independent Skills Building | 54470.50 | |||||||||||||
Nutrition Services Total: | 27505.98 | |||||||||||||
Nutrition Services | 27505.98 | |||||||||||||
Personal Emergency Response System (PERS) Total: | 547822.08 | |||||||||||||
Personal Emergency Response System (PERS) | 547822.08 | |||||||||||||
Transportation Services Total: | 165453.80 | |||||||||||||
Non-Medical Transportation By One Way Trip | 65515.80 | |||||||||||||
Non-Medical Transportation By Mile | 48254.60 | |||||||||||||
Non-Medical Transportation By Hour | 51683.40 | |||||||||||||
|