Application for a §1915(c) Home and Community-Based Services Waiver
PURPOSE OF THE HCBS WAIVER PROGRAM
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.
Request for an Amendment to a §1915(c) Home and Community-Based Services Waiver
1. Request Information
The State of
New York
requests approval for an amendment to the following
Medicaid home and community-based services waiver approved under authority of §1915(c) of the Social Security Act.
Long Term Home Health Care Program
NY.0034
Original Base Waiver Number: NY.0034.
NY.0034.R06.02
04/01/13
09/01/10
2. Purpose(s) of Amendment
Purpose(s) of the Amendment.
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3. Nature of the Amendment
Component(s) of the Approved Waiver Affected by the Amendment. This amendment affects the following component(s) of the approved waiver. Revisions to the affected subsection(s) of these component(s) are being submitted concurrently (check each that applies):
Component of the Approved Waiver
Subsection(s)
Nature of the Amendment. Indicate the nature of the changes to the waiver that are proposed in the amendment (check each that applies):
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Application for a §1915(c) Home and Community-Based Services Waiver
1. Request Information (1 of 3)
The State of
New York
requests approval for a Medicaid home and community-based services (HCBS) waiver under the
authority of §1915(c) of the Social Security Act (the Act).
(optional - this title will be used to locate this waiver in the finder):
amendment
(For new waivers requesting five year approval periods, the waiver must serve individuals who are dually eligible for Medicaid and Medicare.)
Original Base Waiver Number: NY.0034
NY.0034.R06.02
NY.17.06.12
09/01/10
09/01/10
1. Request Information (2
of 3)
Level(s) of Care. This waiver is requested in order to provide
home and community-based waiver services to individuals who, but for
the provision of such services, would require the following level(s) of
care, the costs of which would be reimbursed under the approved Medicaid
State plan (check each that applies):
Select applicable level of care
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Select applicable level of care
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1. Request Information (3 of 3)
Concurrent Operation with Other Programs.This waiver operates concurrently with another program (or programs)
approved under the following authorities
Select one:
Check the applicable authority or authorities:
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Specify the §1915(b) authorities under which this program operates (check each that applies):
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Dual Eligiblity for Medicaid and Medicare.
Check if applicable:
2. Brief Waiver Description
Brief Waiver Description.
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3. Components of the Waiver Request
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-Direction of Services.
When the State provides for participant direction of services, Appendix E specifies the participant direction opportunities that are offered in the waiver and the supports that are available to participants who direct their services. (Select one):
Appendix E is required.
Appendix E is not required.
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.
4. Waiver(s) Requested
Comparability. The State requests a waiver of the requirements contained
in §1902(a)(10)(B) of the Act in order to provide the services specified in
Appendix C that are not otherwise available under the approved Medicaid State
plan to individuals who: (a) require the level(s) of care specified in Item 1.F
and (b) meet the target group criteria specified in Appendix B.
Income and Resources for the Medically Needy.
Indicate whether the State
requests a waiver of §1902(a)(10)(C)(i)(III) of the Act in order to use
institutional income and resource rules for the medically needy (select one):
Statewideness.
Indicate whether the State requests a waiver of the
statewideness requirements in §1902(a)(1) of the Act (select one):
If yes, specify the waiver of statewideness that is requested (check each that applies):
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5. Assurances
In accordance with 42 CFR §441.302, the State provides the following assurances to CMS:
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.
6. Additional Requirements
Note: Item 6-I must be completed.
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/MR.
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.
Public Input.
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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.
7. Contact Person(s)
The Medicaid agency representative with whom CMS should communicate regarding the waiver is:
New York
If applicable, the State operating agency representative with whom CMS should communicate regarding the waiver is:
New York
8. Authorizing Signature
This document, together with the attached revisions to the affected
components of the waiver, constitutes the State's request to amend
its approved waiver under §1915(c) of the Social Security Act.
The State affirms that it will abide by all provisions of the waiver,
including the provisions of this amendment when approved by CMS.
The State further attests that it will continuously operate the waiver
in accordance with the assurances specified in Section V and the
additional requirements specified in Section VI of the approved waiver.
The State certifies that additional proposed revisions to the waiver
request will be submitted by the Medicaid agency in the form of
additional waiver amendments.
State Medicaid Director or Designee
Note: The Signature and Submission Date fields will be automatically completed when the State Medicaid Director submits the application.
New York
Attachment #1: Transition Plan
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Additional Needed Information (Optional)
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Appendix A: Waiver Administration and Operation
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):
(Do not complete item A-2)
(Complete item A-2-a).
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).
Appendix A: Waiver Administration and Operation
Oversight of Performance.
Medicaid Director Oversight of Performance When the Waiver is Operated by another Division/Unit within the State Medicaid Agency.
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Medicaid Agency Oversight of Operating Agency Performance.
As indicated in section 1 of this appendix, the waiver is not operated by a separate agency of the State. Thus this section does not need to be completed.
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Appendix A: Waiver Administration and Operation
Use of Contracted Entities.
Specify whether contracted entities perform waiver operational and administrative functions on behalf of the Medicaid agency and/or the operating agency (if applicable) (select one):
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Appendix A: Waiver Administration and Operation
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):
- Local/regional non-state agencies perform waiver operational and administrative functions.
Check each that applies:
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Appendix A: Waiver Administration and Operation
Responsibility for Assessment of Performance of Contracted and/or Local/Regional Non-State Entities.
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Appendix A: Waiver Administration and Operation
Assessment Methods and Frequency.
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Appendix A: Waiver Administration and Operation
Distribution of Waiver Operational and Administrative Functions.In the following table, specify the entity or entities that have responsibility for
conducting each of the waiver operational and administrative functions listed (check each that applies):
In accordance with 42 CFR §431.10, when the Medicaid agency does not directly conduct a function, it supervises the performance
of the function and establishes and/or approves policies that affect the function.All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. Note: More than one box may be checked per item. Ensure that Medicaid is checked when the Single State Medicaid Agency (1) conducts the function directly; (2) supervises the delegated function; and/or (3) establishes and/or approves policies related to the function.
Function
Medicaid Agency
Local Non-State Entity
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
Appendix A: Waiver Administration and Operation
Quality Improvement: Administrative Authority of the Single State Medicaid Agency
As a distinct component of the State’s quality improvement strategy,
provide information in the following fields to detail the State’s
methods for discovery and remediation.
Methods for Discovery: Administrative Authority
The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.
Performance Measures
For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
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:
Dates and topics of LTHHCP Technical Assistance Group conference calls with the Local Departments of Social Services related to the delegated functions of: Authorizing waiver participation/ enrollment; Waiver enrollment managed against approved levels; Level of care evaluation; Review of participant service plans; authorization of waiver services; Utilization management; other QA/QI activities.
Meeting minutes
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
Performance Measure:
Number and percentage of remediation actions required by State Medicaid Agency
Other
NYSDOH Report of LDSS Case Record and Administrative Review
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
Performance Measure:
Number and percentage of remediation actions required by State Medicaid Agency initiated by LDSSs occurring in a timely fashion.
Other
NYSDOH Follow-up Report of LDSS Case Record and Administrative Review
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
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Methods for Remediation/Fixing Individual Problems
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Remediation Data Aggregation
Remediation-related Data Aggregation and Analysis (including trend identification)
Responsible Party(check each that applies):
Frequency of data aggregation and analysis(check each that applies):
Timelines
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Appendix B: Participant Access and Eligibility
B-1: Specification of the Waiver Target Group(s)
Target Group(s). Under the waiver of Section 1902(a)(10)(B) of the Act, the State limits waiver services to a group or subgroups of individuals. Please see the instruction manual for specifics regarding age limits. In accordance with 42 CFR §441.301(b)(6), select one waiver target group, check each of the subgroups in the selected target group that may receive services under the waiver, and specify the minimum and maximum (if any) age of individuals served in each subgroup:
Target Group
Included
Target SubGroup
Minimum Age
Maximum Age
Maximum Age Limit
No Maximum Age Limit
Aged
Disabled (Physical)
Disabled (Other)
Brain Injury
HIV/AIDS
Medically Fragile
Technology Dependent
Autism
Developmental Disability
Mental Retardation
Mental Illness
Serious Emotional Disturbance
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Appendix B: Participant Access and Eligibility
B-2: Individual Cost Limit (1 of 2)
Individual Cost Limit.
The following individual cost limit applies when determining whether to deny home and community-based services or entrance to the waiver to an otherwise eligible individual (select one)
Please note that a State may have only ONE individual cost limit for the purposes of determining eligibility for the waiver:
The State does not apply an individual cost limit. Do not complete Item B-2-b or item B-2-c.
The State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed the cost of a level of care specified for the waiver up to an amount specified by the State. Complete Items B-2-b and B-2-c.
The limit specified by the State is(select one)
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Pursuant to 42 CFR 441.301(a)(3), the State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed 100% of the cost of the level of care specified for the waiver. Complete Items B-2-b and B-2-c.
The State refuses entrance to the waiver to any otherwise qualified individual when the State reasonably expects that the cost of home and community-based services furnished to that individual would exceed the following amount specified by the State that is less than the cost of a level of care specified for the waiver.
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The cost limit specified by the State is(select one):
The dollar amount(select one)
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Appendix B: Participant Access and Eligibility
B-2: Individual Cost Limit (2 of 2)
Method of Implementation of the Individual Cost Limit.
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Participant Safeguards.
When the State specifies an individual cost limit in Item B-2-a and there is a change
in the participant's condition or circumstances post-entrance to the waiver that requires
the provision of services in an amount that exceeds the cost limit in order to assure the
participant's health and welfare, the State has established the following safeguards to avoid
an adverse impact on the participant (check each that applies):
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Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served (1 of 4)
Unduplicated Number of Participants.
The following table specifies the maximum number of unduplicated participants
who are served in each year that the waiver is in effect. The State will submit
a waiver amendment to CMS to modify the number of participants specified for any
year(s), including when a modification is necessary due to legislative appropriation
or another reason. The number of unduplicated participants specified in this table
is basis for the cost-neutrality calculations in Appendix J:
Table: B-3-a
Waiver Year
Unduplicated Number of Participants
Year 1
Year 2
Year 3
Year 4
Year 5
Limitation on the Number of Participants Served at Any Point in Time.
Consistent with the unduplicated number of participants specified in Item B-3-a, the
State may limit to a lesser number the number of participants who will be served at
any point in time during a waiver year. Indicate whether the State limits the number
of participants in this way: (select one):
Table: B-3-b
Waiver Year
Maximum Number of Participants Served At Any Point During the Year
Year 1
Year 2
Year 3
Year 4
Year 5
Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served (2 of 4)
Reserved Waiver Capacity.
The State may reserve a portion of the participant capacity of the waiver
for specified purposes (e.g., provide for the community transition of
institutionalized persons or furnish waiver services to individuals
experiencing a crisis) subject to CMS review and approval. The State
(select one):
Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served (3 of 4)
Scheduled Phase-In or Phase-Out.
Within a waiver year, the State may make the number of participants who are served subject to a phase-in or phase-out schedule (select one):
Allocation of Waiver Capacity.
Select one:
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Selection of Entrants to the Waiver.
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Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served - Attachment #1 (4 of 4)
Waiver Phase-In/Phase-Out Schedule
Based on Waiver Proposed Effective Date: 09/01/10
The waiver is being (select one):
Phase-In/Phase-Out Time Schedule. Complete the following table:
Phase-In/Phase-Out Schedule
Waiver Year 1
Unduplicated Number of Participants: 22349
Month
Base Number of Participants
Change
Participant Limit
1Sep
22349
22349
2Oct
22349
22349
3Nov
22349
22349
4Dec
22349
22349
5Jan
22349
22349
6Feb
22349
22349
7Mar
22349
22349
8Apr
22349
22349
9May
22349
22349
10Jun
22349
22349
11Jul
22349
22349
12Aug
22349
22349
Waiver Year 2
Unduplicated Number of Participants: 23020
Month
Base Number of Participants
Change
Participant Limit
1Sep
22349
22349
2Oct
22349
22349
3Nov
22349
22349
4Dec
22349
22349
5Jan
22349
22349
6Feb
22349
22349
7Mar
22349
22349
8Apr
22349
22349
9May
22349
22349
10Jun
22349
22349
11Jul
22349
22349
12Aug
22349
22349
Waiver Year 3
Unduplicated Number of Participants: 23711
Month
Base Number of Participants
Change
Participant Limit
1Sep
22349
22349
2Oct
22349
22349
3Nov
22349
22349
4Dec
22349
22349
5Jan
22349
22349
6Feb
22349
22349
7Mar
22349
22349
8Apr
22349
21949
9May
21949
21049
10Jun
21049
19149
11Jul
19149
17249
12Aug
17249
15349
Waiver Year 4
Unduplicated Number of Participants: 15349
Month
Base Number of Participants
Change
Participant Limit
1Sep
15349
12449
2Oct
12449
9949
3Nov
9949
7449
4Dec
7449
5549
5Jan
5549
4649
6Feb
4649
3749
7Mar
3749
3749
8Apr
3749
3749
9May
3749
3749
10Jun
3749
3749
11Jul
3749
3749
12Aug
3749
3749
Waiver Year 5
Unduplicated Number of Participants: 3749
Month
Base Number of Participants
Change
Participant Limit
1Sep
3749
3749
2Oct
3749
3749
3Nov
3749
3749
4Dec
3749
3749
5Jan
3749
3749
6Feb
3749
3749
7Mar
3749
3749
8Apr
3749
3749
9May
3749
3749
10Jun
3749
3749
11Jul
3749
3749
12Aug
3749
3749
Year One
Year Two
Year Three
Year Four
Year Five
Month
Waiver Year
Waiver Year: First Calendar Month
Sep
Phase-in/Phase-out begins
Apr
3
Phase-in/Phase-out ends
Feb
4
Appendix B: Participant Access and Eligibility
B-4: Eligibility Groups Served in the Waiver
State Classification.
The State is a (select one):
Miller Trust State.
Indicate whether the State is a Miller Trust State (select one):
Medicaid Eligibility Groups Served in the Waiver.
Individuals who receive services under this waiver are eligible under the
following eligibility groups contained in the State plan. The State applies
all applicable federal financial participation limits under the plan.
Check all that apply:
Eligibility Groups Served in the Waiver (excluding the special home and community-based waiver group under 42 CFR §435.217)
Select one:
out of 6000
Special home and community-based waiver group under 42 CFR §435.217) Note: When the special home and community-based waiver group under 42 CFR §435.217 is included, Appendix B-5 must be completed
The State does not furnish waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217.Appendix B-5 is not submitted.
The State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217.
Check each that applies:
Select one:
Select one:
out of 6000
Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (1 of 4)
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. A State that uses spousal impoverishment rules under §1924 of the Act to determine the eligibility of individuals with a community spouse may elect to use spousal post-eligibility rules under §1924 of the Act to protect a personal needs allowance for a participant with a community spouse.
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
(select one):
Answers provided in Appendix B-4 indicate that you do not need to submit Appendix B-5 and therefore this section is not visible.
Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (2 of 4)
Regular Post-Eligibility Treatment of Income: SSI State.
Answers provided in Appendix B-4 indicate that you do not need to submit Appendix B-5 and therefore this section is not visible.
Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (3 of 4)
Regular Post-Eligibility Treatment of Income: 209(B) State.
Answers provided in Appendix B-4 indicate that you do not need to submit Appendix B-5 and therefore this section is not visible.
Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (4 of 4)
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).
Answers provided in Appendix B-4 indicate that you do not need to submit Appendix B-5 and therefore this section is not visible.
Appendix B: Participant Access and Eligibility
B-6: Evaluation/Reevaluation of Level of Care
As specified in 42 CFR §441.302(c), the State provides for an evaluation (and periodic reevaluations)
of the need for the level(s) of care specified for this waiver, when there is a reasonable indication
that an individual may need such services in the near future (one month or less), but for the
availability of home and community-based waiver services.
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.
Frequency of services. The State requires (select one):
out of 4000
Responsibility for Performing Evaluations and Reevaluations.
Level of care evaluations and reevaluations are performed (select one):
out of 4000
out of 4000
Qualifications of Individuals Performing Initial Evaluation:
out of 6000
Level of Care Criteria.
out of 12000
Level of Care Instrument(s).
Per 42 CFR §441.303(c)(2), indicate whether the instrument/tool
used to evaluate level of care for the waiver differs from the
instrument/tool used to evaluate institutional level of care
(select one):
out of 12000
Process for Level of Care Evaluation/Reevaluation:
out of 12000
Reevaluation Schedule.
Per 42 CFR §441.303(c)(4), reevaluations of the level of care
required by a participant are conducted no less frequently than
annually according to the following schedule
(select one):
out of 4000
Qualifications of Individuals Who Perform Reevaluations.
Specify the qualifications of individuals who perform reevaluations
(select one):
out of 6000
Procedures to Ensure Timely Reevaluations.
out of 6000
Maintenance of Evaluation/Reevaluation Records.
out of 6000
Appendix B: Evaluation/Reevaluation of Level of Care
Quality Improvement: Level of Care
As a distinct component of the State’s quality improvement strategy,
provide information in the following fields to detail the State’s
methods for discovery and remediation.
Methods for Discovery: Level of Care Assurance/Sub-assurances
Sub-Assurances:
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/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
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 percentage of all new enrollees who have a level of care indicating need for nursing facility level of care, prior to receipt of services.
Other
LDSS Case Records
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
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/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
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 percentage of enrolled waiver participants who are reevaluated at least every 180 days (or more frequently as circumstances warrant)
Other
LDSS Case Records
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
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/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
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 percentage of LOC determinations made by qualified evaluator
Other
LDSS Case Record
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
Performance Measure:
Number and percentage of LOC determination (initial and annual) made on the State’s approved form.
Other
LDSS Case Records
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
Performance Measure:
Number and percentage of LOC criteria that was applied correctly.
Other
LDSS Case Records
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
out of 6000
Methods for Remediation/Fixing Individual Problems
out of 6000
Remediation Data Aggregation
Remediation-related Data Aggregation and Analysis (including trend identification)
Responsible Party(check each that applies):
Frequency of data aggregation and analysis(check each that applies):
Timelines
out of 6000
Appendix B: Participant Access and Eligibility
B-7: Freedom of Choice
Freedom of Choice.
As provided in 42 CFR §441.302(d), when an individual is determined to be likely to require a level of
care for this waiver, the individual or his or her legal representative is:
informed of any feasible alternatives under the waiver; and
given the choice of either institutional or home and community-based services.
Procedures.
out of 12000
Maintenance of Forms.
out of 4000
Appendix B: Participant Access and Eligibility
B-8: Access to Services by Limited English Proficiency Persons
Access to Services by Limited English Proficient Persons.
out of 12000
Appendix C: Participant Services
C-1: Summary of Services Covered (1 of 2)
Waiver Services Summary. List the services that are furnished under the waiver in the following table. If case management is not a service under the waiver, complete items C-1-b and C-1-c:
Service Type
Service
Statutory Service
Respite
Other Service
Assistive Technology
Other Service
Community Transitional Services
Other Service
Congregate and Home Delivered Meals
Other Service
Environmental Modifications
Other Service
Home and Community Support Services
Other Service
Home Maintenance Services
Other Service
Medical Social Services
Other Service
Moving Assistance
Other Service
Nutritional Counseling/Education Services
Other Service
Respiratory Therapy
Other Service
Social Day Care Transportation
Other Service
Social Day Care
Appendix C: Participant Services
C-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).
Service Delivery Method (check each that applies):
Specify whether the service may be provided by
(check each that applies):
Provider Category
Provider Type Title
Agency
Long Term Home Health Care Program (LTHHCP)
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Statutory Service
Service Name: Respite
Provider Qualifications
Verification of Provider Qualifications
Appendix C: Participant Services
C-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.
Service Delivery Method (check each that applies):
Specify whether the service may be provided by
(check each that applies):
Provider Category
Provider Type Title
Agency
Long Term Home Health Care Program (LTHHCP) Agency
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Other Service
Service Name: Assistive Technology
Provider Qualifications
Verification of Provider Qualifications
Appendix C: Participant Services
C-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.
Service Delivery Method (check each that applies):
Specify whether the service may be provided by
(check each that applies):
Provider Category
Provider Type Title
Agency
Long Term Home Health Care Program (LTHHCP) Agency
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Other Service
Service Name: Community Transitional Services
Provider Qualifications
Verification of Provider Qualifications
Appendix C: Participant Services
C-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.
Service Delivery Method (check each that applies):
Specify whether the service may be provided by
(check each that applies):
Provider Category
Provider Type Title
Agency
Long Term Home Health Care Program (LTHHCP) Agency
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Other Service
Service Name: Congregate and Home Delivered Meals
Provider Qualifications
Verification of Provider Qualifications
Appendix C: Participant Services
C-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.
Service Delivery Method (check each that applies):
Specify whether the service may be provided by
(check each that applies):
Provider Category
Provider Type Title
Agency
Long Term Home Health Care Program (LTHHCP) Agency
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Other Service
Service Name: Environmental Modifications
Provider Qualifications
Verification of Provider Qualifications
Appendix C: Participant Services
C-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.
Service Delivery Method (check each that applies):
Specify whether the service may be provided by
(check each that applies):
Provider Category
Provider Type Title
Agency
Long Term Home Health Care Program (LTHHCP) Agency
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Other Service
Service Name: Home and Community Support Services
Provider Qualifications
Verification of Provider Qualifications
Appendix C: Participant Services
C-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.
Service Delivery Method (check each that applies):
Specify whether the service may be provided by
(check each that applies):
Provider Category
Provider Type Title
Agency
Long Term Home Health Care Program Agency
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Other Service
Service Name: Home Maintenance Services
Provider Qualifications
Verification of Provider Qualifications
Appendix C: Participant Services
C-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.
Service Delivery Method (check each that applies):
Specify whether the service may be provided by
(check each that applies):
Provider Category
Provider Type Title
Agency
Long Term Home Health Care Program (LTHHCP) Agency
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Other Service
Service Name: Medical Social Services
Provider Qualifications
Verification of Provider Qualifications
Appendix C: Participant Services
C-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.
Service Delivery Method (check each that applies):
Specify whether the service may be provided by
(check each that applies):
Provider Category
Provider Type Title
Agency
Long Term Home Health Care Program (LTHHCP)
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Other Service
Service Name: Moving Assistance
Provider Qualifications
Verification of Provider Qualifications
Appendix C: Participant Services
C-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.
Service Delivery Method (check each that applies):
Specify whether the service may be provided by
(check each that applies):
Provider Category
Provider Type Title
Agency
Long Term Home Health Care Program (LTHHCP) Agency
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Other Service
Service Name: Nutritional Counseling/Education Services
Provider Qualifications
Verification of Provider Qualifications
Appendix C: Participant Services
C-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.
Service Delivery Method (check each that applies):
Specify whether the service may be provided by
(check each that applies):
Provider Category
Provider Type Title
Agency
Long Term Home Health Care Program (LTHHCP) Agency
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Other Service
Service Name: Respiratory Therapy
Provider Qualifications
Verification of Provider Qualifications
Appendix C: Participant Services
C-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.
Service Delivery Method (check each that applies):
Specify whether the service may be provided by
(check each that applies):
Provider Category
Provider Type Title
Agency
Long Term Home Health Care Program (LTHHCP) Agency
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Other Service
Service Name: Social Day Care Transportation
Provider Qualifications
Verification of Provider Qualifications
Appendix C: Participant Services
C-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.
Service Delivery Method (check each that applies):
Specify whether the service may be provided by
(check each that applies):
Provider Category
Provider Type Title
Agency
Long Term Home Health Care Program (LTHHCP) Agency
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Other Service
Service Name: Social Day Care
Provider Qualifications
Verification of Provider Qualifications
Appendix C: Participant Services
C-1: Summary of Services Covered (2 of 2)
Provision of Case Management Services to Waiver Participants.
Indicate how case management is furnished to waiver participants (select one):
- Case management is not furnished as a distinct activity to waiver participants.
- Case management is furnished as a distinct activity to waiver participants.
Check each that applies:
Do not complete item C-1-c.
Complete item C-1-c.
Complete item C-1-c.
Complete item C-1-c. NOTE: Pursuant to CMS-2237-IFC this selection is no longer available for 1915(c) waivers.
Do not complete item C-1-c.
- Case management is furnished as a waiver service (Do not complete item C-1-c).
Delivery of Case Management Services.
out of 4000
Appendix C: Participant Services
C-2: General Service Specifications (1 of 3)
Criminal History and/or Background Investigations.
out of 12000
Abuse Registry Screening.
out of 12000
Appendix C: Participant Services
C-2: General Service Specifications (2 of 3)
Services in Facilities Subject to §1616(e) of the Social Security Act. Select one:
Facility Type
Enriched Housing
Adult Home
Residences for Adults
out of 12000
Appendix C: Participant Services
C-2: Facility Specifications
Waiver Service
Provided in Facility
Moving Assistance
Home and Community Support Services
Respite
Community Transitional Services
Assistive Technology
Environmental Modifications
Home Maintenance Services
Congregate and Home Delivered Meals
Social Day Care Transportation
Social Day Care
Medical Social Services
Respiratory Therapy
Nutritional Counseling/Education Services
Scope of Facility Sandards. For this facility type, please specify whether the State's standards address the following topics (check each that applies):
Scope of State Facility Standards
Standard
Topic Addressed
Admission policies
Physical environment
Sanitation
Safety
Staff : resident ratios
Staff training and qualifications
Staff supervision
Resident rights
Medication administration
Use of restrictive interventions
Incident reporting
Provision of or arrangement for necessary health services
Appendix C: Participant Services
C-2: Facility Specifications
Waiver Service
Provided in Facility
Moving Assistance
Home and Community Support Services
Respite
Community Transitional Services
Assistive Technology
Environmental Modifications
Home Maintenance Services
Congregate and Home Delivered Meals
Social Day Care Transportation
Social Day Care
Medical Social Services
Respiratory Therapy
Nutritional Counseling/Education Services
Scope of Facility Sandards. For this facility type, please specify whether the State's standards address the following topics (check each that applies):
Scope of State Facility Standards
Standard
Topic Addressed
Admission policies
Physical environment
Sanitation
Safety
Staff : resident ratios
Staff training and qualifications
Staff supervision
Resident rights
Medication administration
Use of restrictive interventions
Incident reporting
Provision of or arrangement for necessary health services
Appendix C: Participant Services
C-2: Facility Specifications
Waiver Service
Provided in Facility
Moving Assistance
Home and Community Support Services
Respite
Community Transitional Services
Assistive Technology
Environmental Modifications
Home Maintenance Services
Congregate and Home Delivered Meals
Social Day Care Transportation
Social Day Care
Medical Social Services
Respiratory Therapy
Nutritional Counseling/Education Services
Scope of Facility Sandards. For this facility type, please specify whether the State's standards address the following topics (check each that applies):
Scope of State Facility Standards
Standard
Topic Addressed
Admission policies
Physical environment
Sanitation
Safety
Staff : resident ratios
Staff training and qualifications
Staff supervision
Resident rights
Medication administration
Use of restrictive interventions
Incident reporting
Provision of or arrangement for necessary health services
Appendix C: Participant Services
C-2: General Service Specifications (3 of 3)
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:
out of 12000
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:
out of 12000
out of 12000
out of 12000
Open Enrollment of Providers.
out of 12000
Appendix C: Participant Services
Quality Improvement: Qualified Providers
As a distinct component of the State’s quality improvement strategy,
provide information in the following fields to detail the State’s
methods for discovery and remediation.
Methods for Discovery: Qualified Providers
Sub-Assurances:
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/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
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:
The number and percentage of new applications for enrollment as a LTHHCP agency in which the provider obtained appropriate licensure/certification in accordance with state law and waiver provider qualifications prior to service provision.
Other
Monthly reports from NYSDOH Licensure/ Certification Staff
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
Performance Measure:
Number and percentage of LTHHCP agencies who continue to meet applicable licensure/certification following initial enrollment.
Other
LTHHCP agency NYSDOH surveillance reports
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
Sub-Assurance: The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements.
For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
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 percentage of non-licensed/non-certified providers under contract with a LTHHCP agency who continue to meet waiver provider qualifications (NYSDOH surveillance through agency survey)
Other
LTHHCP agency NYSDOH surveillance reports
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
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/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
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 percentage of LTHHCP agencies that are compliant with professional standards and principles (NYSDOH surveillance through agency survey)
Other
LTHHCP agency NYSDOH surveillance reports
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
Performance Measure:
Number and percentage enrolled service providers, by provider type, meeting training requirements.
Other
Attendance sheets of regional meetings/ focus groups/ training seminars/ webinars for training purposes.
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
out of 6000
Methods for Remediation/Fixing Individual Problems
out of 6000
Remediation Data Aggregation
Remediation-related Data Aggregation and Analysis (including trend identification)
Responsible Party(check each that applies):
Frequency of data aggregation and analysis(check each that applies):
Timelines
out of 6000
Appendix C: Participant Services
C-3: Waiver Services Specifications
Section C-3 'Service Specifications' is incorporated into Section C-1 'Waiver Services.'
Appendix C: Participant Services
C-4: Additional Limits on Amount of 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).
- The State does not impose a limit on the amount of waiver services except as provided in Appendix C-3.
- The State imposes additional limits on the amount of waiver services.
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)
out of 24000
out of 24000
out of 24000
out of 24000
Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (1 of 8)
Responsibility for Service Plan Development.
Per 42 CFR §441.301(b)(2), specify who is responsible for the
development of the service plan and the qualifications of these
individuals (select each that applies):
out of 6000
out of 6000
out of 6000
Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (2 of 8)
Service Plan Development Safeguards.Select one:
out of 6000
Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (3 of 8)
Supporting the Participant in Service Plan Development.
out of 12000
Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (4 of 8)
Service Plan Development Process.
out of 24000
Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (5 of 8)
Risk Assessment and Mitigation.
out of 12000
Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (6 of 8)
Informed Choice of Providers.
out of 6000
Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (7 of 8)
Process for Making Service Plan Subject to the Approval of the Medicaid Agency.
out of 6000
Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (8 of 8)
Service Plan Review and Update.
The service plan is subject to at least annual periodic review and
update to assess the appropriateness and adequacy of the services as
participant needs change.
out of 6000
Maintenance of Service Plan Forms.
Written copies or electronic facsimiles of service plans are
maintained for a minimum period of 3 years as required by 45 CFR §92.42.
Service plans are maintained by the following
(check each that applies):
out of 4000
Appendix D: Participant-Centered Planning and Service Delivery
D-2: Service Plan Implementation and Monitoring
Service Plan Implementation and Monitoring.
out of 24000
Monitoring Safeguards.Select one:
out of 24000
Appendix D: Participant-Centered Planning and Service Delivery
Quality Improvement: Service Plan
As a distinct component of the State’s quality improvement strategy,
provide information in the following fields to detail the State’s
methods for discovery and remediation.
Methods for Discovery: Service Plan Assurance/Sub-assurances
Sub-Assurances:
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/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
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 percentage of waiver participants who have plan of care that is adequate and appropriate to their needs (including health and safety factors) and personal goals identified in the comprehensive assessment. (NYSDOH waiver management staff review of LDSS case records)
Other
LDSS case records
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
Sub-assurance: The State monitors service plan development in accordance with its policies and procedures.
Performance Measures
For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
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 percentage of waiver participants whose plan of care development was based upon completion of a joint home visit by LTHHCP agency RN and LDSS staff and completion of the Home Assessment Abstract tool. (NYSDOH waiver management staff review of LDSS case records)
Other
LDSS case records
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
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/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
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 percentage of plan of care (Home Assessment Abstract) are reviewed and revised at least every 180 days (NYSDOH waiver management staff review of LDSS case records)
Other
LDSS case records
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
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/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
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 percentage of waiver participants who received services in the type, amount, frequency and duration specified in the plan of care. (comparison of plan of care and claims data via NYSDOH waiver management staff review of LDSS case record )
Other
LDSS case records
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
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/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
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 percentage of waiver participants whose records contain appropriately completed and signed freedom of choice form that specifies choice was offered. (NYSDOH waiver management staff review of LDSS case record )
Other
LDSS case records
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
out of 6000
Methods for Remediation/Fixing Individual Problems
out of 6000
Remediation Data Aggregation
Remediation-related Data Aggregation and Analysis (including trend identification)
Responsible Party(check each that applies):
Frequency of data aggregation and analysis(check each that applies):
Timelines
out of 6000
Appendix E: Participant Direction of Services
Applicability(from Application Section 3, Components of the Waiver Request):
Complete the remainder of the Appendix.
Do not complete the remainder of the Appendix.
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):
Appendix E: Participant Direction of Services
E-1: Overview (1 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (2 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (3 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (4 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (5 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (6 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (7 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (8 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (9 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (10 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (11 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (12 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (13 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-2: Opportunities for Participant Direction (1 of 6)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-2: Opportunities for Participant-Direction (2 of 6)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-2: Opportunities for Participant-Direction (3 of 6)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-2: Opportunities for Participant-Direction (4 of 6)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-2: Opportunities for Participant-Direction (5 of 6)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-2: Opportunities for Participant-Direction (6 of 6)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix F: Participant Rights
Appendix F-1: Opportunity to Request a Fair Hearing
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.
out of 12000
Appendix F: Participant-Rights
Appendix F-2: Additional Dispute Resolution Process
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.
out of 12000
Appendix F: Participant-Rights
Appendix F-3: State Grievance/Complaint System
Operation of Grievance/Complaint System.Select one:
Operational Responsibility.
out of 4000
Description of System.
out of 12000
Appendix G: Participant Safeguards
Appendix G-1: Response to Critical Events or Incidents
Critical Event or Incident Reporting and Management Process.
(complete Items b through e)
(do not complete Items b through e)
out of 12000
State Critical Event or Incident Reporting Requirements.
out of 24000
Participant Training and Education.
out of 12000
Responsibility for Review of and Response to Critical Events or Incidents.
out of 12000
Responsibility for Oversight of Critical Incidents and Events.
out of 12000
Appendix G: Participant Safeguards
Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (1 of 2)
Use of Restraints or Seclusion.(Select one):
out of 12000
. Complete Items G-2-a-i and G-2-a-ii.
Safeguards Concerning the Use of Restraints or Seclusion.
out of 12000
State Oversight Responsibility.
out of 12000
Appendix G: Participant Safeguards
Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (2 of 2)
Use of Restrictive Interventions.(Select one):
out of 12000
Complete Items G-2-b-i and G-2-b-ii.
Safeguards Concerning the Use of Restrictive Interventions.
out of 20000
State Oversight Responsibility.
out of 20000
Appendix G: Participant Safeguards
Appendix G-3: Medication Management and Administration (1 of 2)
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:
(do not complete the remaining items)
(complete the remaining items)
Medication Management and Follow-Up
Responsibility.
out of 12000
Methods of State Oversight and Follow-Up.
out of 12000
Appendix G: Participant Safeguards
Appendix G-3: Medication Management and Administration (2 of 2)
Medication Administration by Waiver Providers
Provider Administration of Medications.Select one:
(do not complete the remaining items)
(complete the remaining items)
State Policy.
out of 12000
Medication Error Reporting.Select one of the following:
Complete the following three items:
out of 12000
out of 12000
out of 12000
out of 12000
State Oversight Responsibility.
out of 12000
Appendix G: Participant Safeguards
Quality Improvement: Health and Welfare
As a distinct component of the State’s quality improvement strategy,
provide information in the following fields to detail the State’s
methods for discovery and remediation.
Methods for Discovery: Health and Welfare
The State, on an ongoing basis, identifies, addresses and seeks to prevent the occurrence of abuse, neglect and exploitation.
Performance Measures
For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
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 of issues/deficiencies identified by NYSDOH Surveillance during survey or by complaint investigation and reported to NYSDOH waiver management staff related to LTHHCP participant’s health and welfare.
Other
LTHHCP Agency Survey Reports
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Other
Complaint Hotline
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
Performance Measure:
Number and percentage of reportable incidences for abuse, neglect and/or exploitation requiring referral to APS/CPS. (NYSDOH waiver management review of LDSS case records)
Other
LDSS Case Records
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
out of 6000
Methods for Remediation/Fixing Individual Problems
out of 6000
Remediation Data Aggregation
Remediation-related Data Aggregation and Analysis (including trend identification)
Responsible Party(check each that applies):
Frequency of data aggregation and analysis(check each that applies):
Timelines
out of 6000
Appendix H: Quality Improvement Strategy (1 of 2)
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.
Quality Improvement is a critical operational feature that an organization employs to continually determine whether it operates in accordance with the approved design of its program, meets statutory and regulatory assurances and requirements, achieves desired outcomes, and identifies opportunities for improvement.
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.
Quality Improvement Strategy: Minimum Components
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 QMS discovery and remediation sections throughout the application (located in Appendices A, B, C, D, G, and I) , a state spells out:
The evidence based discovery activities that will be conducted for each of the six major waiver assurances;
The remediation activities followed to correct individual problems identified in the implementation of each of the assurances;
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 QMS 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 QMS spans more than one waiver, the State must be able to stratify information that is related to each approved waiver program.
Appendix H: Quality Improvement Strategy (2 of 2)
H-1: Systems Improvement
System Improvements
out of 12000
System Improvement Activities
Responsible Party(check each that applies):
Frequency of Monitoring and Analysis(check each that applies):
System Design Changes
out of 12000
out of 12000
Appendix I: Financial Accountability
I-1: Financial Integrity and Accountability
Financial Integrity.
out of 12000
Appendix I: Financial Accountability
Quality Improvement: Financial Accountability
As a distinct component of the State’s quality improvement strategy,
provide information in the following fields to detail the State’s
methods for discovery and remediation.
Methods for Discovery: Financial Accountability
State financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver.
Performance Measures
For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
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 percentage of case reviews in which services were coded and paid consistent with the participant’s Plan of Care.
Other
LDSS Case Records and Claim Detail Reports
Responsible Party for data collection/generation(check each that applies):
Frequency of data collection/generation(check each that applies):
Sampling Approach(check each that applies):
Data Aggregation and Analysis:
Responsible Party for data aggregation and analysis (check each that applies):
Frequency of data aggregation and analysis(check each that applies):
out of 6000
Methods for Remediation/Fixing Individual Problems
out of 6000
Remediation Data Aggregation
Remediation-related Data Aggregation and Analysis (including trend identification)
Responsible Party(check each that applies):
Frequency of data aggregation and analysis(check each that applies):
Timelines
out of 6000
Appendix I: Financial Accountability
I-2: Rates, Billing and Claims (1 of 3)
Rate Determination Methods.
out of 12000
Flow of Billings.
out of 6000
Appendix I: Financial Accountability
I-2: Rates, Billing and Claims (2 of 3)
Certifying Public Expenditures(select one):
Select at least one:
out of 6000
out of 6000
Appendix I: Financial Accountability
I-2: Rates, Billing and Claims (3 of 3)
Billing Validation Process.
out of 6000
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.
Appendix I: Financial Accountability
I-3: Payment (1 of 7)
Method of payments -- MMIS
(select one):
out of 6000
out of 6000
out of 6000
Appendix I: Financial Accountability
I-3: Payment (2 of 7)
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):
out of 6000
out of 6000
Appendix I: Financial Accountability
I-3: Payment (3 of 7)
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:
out of 6000
Appendix I: Financial Accountability
I-3: Payment (4 of 7)
Payments to State or Local Government Providers.Specify whether State or local government providers receive payment for the provision of waiver services.
Do not complete Item I-3-e.
Complete Item I-3-e.
out of 4000
Appendix I: Financial Accountability
I-3: Payment (5 of 7)
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:
out of 6000
Appendix I: Financial Accountability
I-3: Payment (6 of 7)
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:
out of 12000
out of 12000
Appendix I: Financial Accountability
I-3: Payment (7 of 7)
Additional Payment Arrangements
Voluntary Reassignment of Payments to a Governmental Agency.Select one:
out of 4000
Organized Health Care Delivery System.Select one:
out of 18000
Contracts with MCOs, PIHPs or PAHPs.Select one:
out of 18000
Appendix I: Financial Accountability
I-4: Non-Federal Matching Funds (1 of 3)
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:
out of 6000
out of 6000
Appendix I: Financial Accountability
I-4: Non-Federal Matching Funds (2 of 3)
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:
. There are no local government level sources of funds utilized as the non-federal share.
Check each that applies:
out of 6000
out of 6000
Appendix I: Financial Accountability
I-4: Non-Federal Matching Funds (3 of 3)
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:
Check each that applies:
out of 6000
Appendix I: Financial Accountability
I-5: Exclusion of Medicaid Payment for Room and Board
Services Furnished in Residential Settings.Select one:
Method for Excluding the Cost of Room and Board Furnished in Residential Settings.
out of 12000
Appendix I: Financial Accountability
I-6: Payment for Rent and Food Expenses of an Unrelated Live-In Caregiver
Reimbursement for the Rent and Food Expenses of an Unrelated Live-In Personal Caregiver.Select one:
out of 6000
Appendix I: Financial Accountability
I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (1 of 5)
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):
out of 6000
Appendix I: Financial Accountability
I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (2 of 5)
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.
Appendix I: Financial Accountability
I-7: Participant Co-Payments for Waiver
Services and Other Cost Sharing (3 of 5)
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.
Appendix I: Financial Accountability
I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (4 of 5)
Co-Payment Requirements.
Cumulative Maximum Charges.
Answers provided in Appendix I-7-a indicate that you do not need to complete this section.
Appendix I: Financial Accountability
I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (5 of 5)
Other State Requirement for Cost Sharing.
Specify whether the State imposes a premium, enrollment fee or similar cost sharing on
waiver participants. Select one:
out of 12000
Appendix J: Cost Neutrality Demonstration
J-1: Composite Overview and Demonstration of Cost-Neutrality Formula
Composite Overview.
Nursing Facility
Col. 1
Col. 2
Col. 3
Col. 4
Col. 5
Col. 6
Col. 7
Col. 8
Year
Factor D
Factor D'
Total: D+D'
Factor G
Factor G'
Total: G+G'
Difference (Col 7 less Column4)
1
1895.27
32216.27
61905.00
29688.73
2
1927.35
32590.35
63920.00
31329.65
3
1696.35
32704.35
66001.00
33296.65
4
1016.17
32374.17
68151.00
35776.83
5
801.30
32512.30
70372.00
37859.70
Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (1 of 9)
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:
Table: J-2-a: Unduplicated Participants
Waiver Year
Total Number Unduplicated Number of Participants (from Item B-3-a)
Distribution of Unduplicated Participants by Level of Care (if applicable)
Level of Care:
Nursing Facility
Year 1
22349
Year 2
23020
Year 3
23711
Year 4
15349
Year 5
3749
Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (2 of 9)
Average Length of Stay.
out of 6000
Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (3 of 9)
Derivation of Estimates for Each Factor. Provide a narrative description for the derivation of the estimates of the following factors.
out of 12000
out of 12000
out of 12000
out of 12000
Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (4 of 9)
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
Respite
Assistive Technology
Community Transitional Services
Congregate and Home Delivered Meals
Environmental Modifications
Home and Community Support Services
Home Maintenance Services
Medical Social Services
Moving Assistance
Nutritional Counseling/Education Services
Respiratory Therapy
Social Day Care Transportation
Social Day Care
Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (5 of 9)
Estimate of Factor D.
i. Non-Concurrent Waiver.
Waiver Service/ Component
Capi-tation
Unit
# Users
Avg. Units Per User
Avg. Cost/ Unit
Component Cost
Total Cost
Respite Total:
348546.24
Respite
348546.24
Assistive Technology Total:
4936499.20
Assistive Technology
4936499.20
Community Transitional Services Total:
261673.56
Community Transitional Services
261673.56
Congregate and Home Delivered Meals Total:
4629039.80
Congregate and Home Delivered Meals
4629039.80
Environmental Modifications Total:
388068.00
Environmental Modifications
388068.00
Home and Community Support Services Total:
4739245.00
Home and Community Support Services
4739245.00
Home Maintenance Services Total:
343137.69
Home Maintenance Services
343137.69
Medical Social Services Total:
17194432.80
Medical Social Services
17194432.80
Moving Assistance Total:
31813.65
Moving Assistance
31813.65
Nutritional Counseling/Education Services Total:
3246189.42
Nutritional Counseling/Education Services
3246189.42
Respiratory Therapy Total:
778498.56
Respiratory Therapy
778498.56
Social Day Care Transportation Total:
1969098.00
Social Day Care Transportation
1969098.00
Social Day Care Total:
3491232.03
Social Day Care
3491232.03
GRAND TOTAL:
42357473.95
Total Estimated Unduplicated Participants:
22349
Factor D (Divide total by number of participants):
1895.27
Average Length of Stay on the Waiver:
Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (6 of 9)
Estimate of Factor D.
i. Non-Concurrent Waiver.
Waiver Service/ Component
Capi-tation
Unit
# Users
Avg. Units Per User
Avg. Cost/ Unit
Component Cost
Total Cost
Respite Total:
365268.80
Respite
365268.80
Assistive Technology Total:
5157569.91
Assistive Technology
5157569.91
Community Transitional Services Total:
273660.20
Community Transitional Services
273660.20
Congregate and Home Delivered Meals Total:
4911188.16
Congregate and Home Delivered Meals
4911188.16
Environmental Modifications Total:
399456.00
Environmental Modifications
399456.00
Home and Community Support Services Total:
4960410.00
Home and Community Support Services
4960410.00
Home Maintenance Services Total:
354936.40
Home Maintenance Services
354936.40
Medical Social Services Total:
17996848.32
Medical Social Services
17996848.32
Moving Assistance Total:
33308.10
Moving Assistance
33308.10
Nutritional Counseling/Education Services Total:
3397526.40
Nutritional Counseling/Education Services
3397526.40
Respiratory Therapy Total:
814884.00
Respiratory Therapy
814884.00
Social Day Care Transportation Total:
2028962.00
Social Day Care Transportation
2028962.00
Social Day Care Total:
3673621.80
Social Day Care
3673621.80
GRAND TOTAL:
44367640.09
Total Estimated Unduplicated Participants:
23020
Factor D (Divide total by number of participants):
1927.35
Average Length of Stay on the Waiver:
Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (7 of 9)
Estimate of Factor D.
i. Non-Concurrent Waiver.
Waiver Service/ Component
Capi-tation
Unit
# Users
Avg. Units Per User
Avg. Cost/ Unit
Component Cost
Total Cost
Respite Total:
331453.76
Respite
331453.76
Assistive Technology Total:
4678614.00
Assistive Technology
4678614.00
Community Transitional Services Total:
249236.30
Community Transitional Services
249236.30
Congregate and Home Delivered Meals Total:
4458246.40
Congregate and Home Delivered Meals
4458246.40
Environmental Modifications Total:
356532.00
Environmental Modifications
356532.00
Home and Community Support Services Total:
4499572.00
Home and Community Support Services
4499572.00
Home Maintenance Services Total:
317520.42
Home Maintenance Services
317520.42
Medical Social Services Total:
16333382.08
Medical Social Services
16333382.08
Moving Assistance Total:
29866.50
Moving Assistance
29866.50
Nutritional Counseling/Education Services Total:
3083412.00
Nutritional Counseling/Education Services
3083412.00
Respiratory Therapy Total:
739699.80
Respiratory Therapy
739699.80
Social Day Care Transportation Total:
1810886.00
Social Day Care Transportation
1810886.00
Social Day Care Total:
3333821.04
Social Day Care
3333821.04
GRAND TOTAL:
40222242.30
Total Estimated Unduplicated Participants:
23711
Factor D (Divide total by number of participants):
1696.35
Average Length of Stay on the Waiver:
Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (8 of 9)
Estimate of Factor D.
i. Non-Concurrent Waiver.
Waiver Service/ Component
Capi-tation
Unit
# Users
Avg. Units Per User
Avg. Cost/ Unit
Component Cost
Total Cost
Respite Total:
129149.68
Respite
129149.68
Assistive Technology Total:
1813778.16
Assistive Technology
1813778.16
Community Transitional Services Total:
95978.16
Community Transitional Services
95978.16
Congregate and Home Delivered Meals Total:
1730282.64
Congregate and Home Delivered Meals
1730282.64
Environmental Modifications Total:
136656.00
Environmental Modifications
136656.00
Home and Community Support Services Total:
1751946.00
Home and Community Support Services
1751946.00
Home Maintenance Services Total:
121837.75
Home Maintenance Services
121837.75
Medical Social Services Total:
6336469.84
Medical Social Services
6336469.84
Moving Assistance Total:
12141.00
Moving Assistance
12141.00
Nutritional Counseling/Education Services Total:
1196322.90
Nutritional Counseling/Education Services
1196322.90
Respiratory Therapy Total:
287450.24
Respiratory Therapy
287450.24
Social Day Care Transportation Total:
690574.00
Social Day Care Transportation
690574.00
Social Day Care Total:
1294670.70
Social Day Care
1294670.70
GRAND TOTAL:
15597257.07
Total Estimated Unduplicated Participants:
15349
Factor D (Divide total by number of participants):
1016.17
Average Length of Stay on the Waiver:
Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (9 of 9)
Estimate of Factor D.
i. Non-Concurrent Waiver.
Waiver Service/ Component
Capi-tation
Unit
# Users
Avg. Units Per User
Avg. Cost/ Unit
Component Cost
Total Cost
Respite Total:
25062.08
Respite
25062.08
Assistive Technology Total:
348308.55
Assistive Technology
348308.55
Community Transitional Services Total:
18964.89
Community Transitional Services
18964.89
Congregate and Home Delivered Meals Total:
334180.80
Congregate and Home Delivered Meals
334180.80
Environmental Modifications Total:
26280.00
Environmental Modifications
26280.00
Home and Community Support Services Total:
331870.00
Home and Community Support Services
331870.00
Home Maintenance Services Total:
22910.87
Home Maintenance Services
22910.87
Medical Social Services Total:
1225866.80
Medical Social Services
1225866.80
Moving Assistance Total:
2056.20
Moving Assistance
2056.20
Nutritional Counseling/Education Services Total:
231403.20
Nutritional Counseling/Education Services
231403.20
Respiratory Therapy Total:
55727.56
Respiratory Therapy
55727.56
Social Day Care Transportation Total:
132556.00
Social Day Care Transportation
132556.00
Social Day Care Total:
248900.40
Social Day Care
248900.40
GRAND TOTAL:
3004087.35
Total Estimated Unduplicated Participants:
3749
Factor D (Divide total by number of participants):