The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in §1915(c) of the Social Security Act. The program permits a State to furnish an array of home and community-based services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. The State has broad discretion to design its waiver program to address the needs of the waivers target population. Waiver services complement and/or supplement the services that are available to participants through the Medicaid State plan and other federal, state and local public programs as well as the supports that families and communities provide.
The Centers for Medicare & Medicaid Services (CMS) recognizes that the design and operational features of a waiver program will vary depending on the specific needs of the target population, the resources available to the State, service delivery system structure, State goals and objectives, and other factors. A State has the latitude to design a waiver program that is cost-effective and employs a variety of service delivery approaches, including participant direction of services.
Component of the Approved Waiver | Subsection(s) |
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The waiver application consists of the following components. Note: Item 3-E must be completed.
Waiver Administration and Operation. Appendix A specifies the administrative and operational structure of this waiver.
Participant Access and Eligibility. Appendix B specifies the target group(s) of individuals who are served in this waiver, the number of participants that the State expects to serve during each year that the waiver is in effect, applicable Medicaid eligibility and post-eligibility (if applicable) requirements, and procedures for the evaluation and reevaluation of level of care.
Participant Services. Appendix C specifies the home and community-based waiver services that are furnished through the waiver, including applicable limitations on such services.
Participant-Centered Service Planning and Delivery. Appendix D specifies the procedures and methods that the State uses to develop, implement and monitor the participant-centered service plan (of care).
Participant Rights. Appendix F specifies how the State informs participants of their Medicaid Fair Hearing rights and other procedures to address participant grievances and complaints.
Participant Safeguards. Appendix G describes the safeguards that the State has established to assure the health and welfare of waiver participants in specified areas.
Quality Improvement Strategy. Appendix H contains the Quality Improvement Strategy for this waiver.
Financial Accountability. Appendix I describes the methods by which the State makes payments for waiver services, ensures the integrity of these payments, and complies with applicable federal requirements concerning payments and federal financial participation.
Cost-Neutrality Demonstration. Appendix J contains the State's demonstration that the waiver is cost-neutral.
Health & Welfare: The State assures that necessary safeguards have been taken to protect the health and welfare of persons receiving services under this waiver. These safeguards include:
As specified in Appendix C, adequate standards for all types of providers that provide services under this waiver;
Assurance that the standards of any State licensure or certification requirements specified in Appendix C are met for services or for individuals furnishing services that are provided under the waiver. The State assures that these requirements are met on the date that the services are furnished; and,
Assurance that all facilities subject to §1616(e) of the Act where home and community-based waiver services are provided comply with the applicable State standards for board and care facilities as specified in Appendix C.
Financial Accountability. The State assures financial accountability for funds expended for home and community-based services and maintains and makes available to the Department of Health and Human Services (including the Office of the Inspector General), the Comptroller General, or other designees, appropriate financial records documenting the cost of services provided under the waiver. Methods of financial accountability are specified in Appendix I.
Evaluation of Need: The State assures that it provides for an initial evaluation (and periodic reevaluations, at least annually) of the need for a level of care specified for this waiver, when there is a reasonable indication that an individual might need such services in the near future (one month or less) but for the receipt of home and community-based services under this waiver. The procedures for evaluation and reevaluation of level of care are specified in Appendix B.
Choice of Alternatives: The State assures that when an individual is determined to be likely to require the level of care specified for this waiver and is in a target group specified in Appendix B, the individual (or, legal representative, if applicable) is:
Informed of any feasible alternatives under the waiver; and,
Given the choice of either institutional or home and community-based waiver services. Appendix B specifies the procedures that the State employs to ensure that individuals are informed of feasible alternatives under the waiver and given the choice of institutional or home and community-based waiver services.
Average Per Capita Expenditures: The State assures that, for any year that the waiver is in effect, the average per capita expenditures under the waiver will not exceed 100 percent of the average per capita expenditures that would have been made under the Medicaid State plan for the level(s) of care specified for this waiver had the waiver not been granted. Cost-neutrality is demonstrated in Appendix J.
Actual Total Expenditures: The State assures that the actual total expenditures for home and community-based waiver and other Medicaid services and its claim for FFP in expenditures for the services provided to individuals under the waiver will not, in any year of the waiver period, exceed 100 percent of the amount that would be incurred in the absence of the waiver by the State's Medicaid program for these individuals in the institutional setting(s) specified for this waiver.
Institutionalization Absent Waiver: The State assures that, absent the waiver, individuals served in the waiver would receive the appropriate type of Medicaid-funded institutional care for the level of care specified for this waiver.
Reporting: The State assures that annually it will provide CMS with information concerning the impact of the waiver on the type, amount and cost of services provided under the Medicaid State plan and on the health and welfare of waiver participants. This information will be consistent with a data collection plan designed by CMS.
Habilitation Services. The State assures that prevocational, educational, or supported employment services, or a combination of these services, if provided as habilitation services under the waiver are: (1) not otherwise available to the individual through a local educational agency under the Individuals with Disabilities Education Act (IDEA) or the Rehabilitation Act of 1973; and, (2) furnished as part of expanded habilitation services.
Services for Individuals with Chronic Mental Illness. The State assures that federal financial participation (FFP) will not be claimed in expenditures for waiver services including, but not limited to, day treatment or partial hospitalization, psychosocial rehabilitation services, and clinic services provided as home and community-based services to individuals with chronic mental illnesses if these individuals, in the absence of a waiver, would be placed in an IMD and are: (1) age 22 to 64; (2) age 65 and older and the State has not included the optional Medicaid benefit cited in 42 CFR §440.140; or (3) age 21 and under and the State has not included the optional Medicaid benefit cited in 42 CFR § 440.160.
Service Plan. In accordance with 42 CFR §441.301(b)(1)(i), a participant-centered service plan (of care) is developed for each participant employing the procedures specified in Appendix D. All waiver services are furnished pursuant to the service plan. The service plan describes: (a) the waiver services that are furnished to the participant, their projected frequency and the type of provider that furnishes each service and (b) the other services (regardless of funding source, including State plan services) and informal supports that complement waiver services in meeting the needs of the participant. The service plan is subject to the approval of the Medicaid agency. Federal financial participation (FFP) is not claimed for waiver services furnished prior to the development of the service plan or for services that are not included in the service plan.
Inpatients. In accordance with 42 CFR §441.301(b)(1)(ii), waiver services are not furnished to individuals who are in-patients of a hospital, nursing facility or ICF/IID.
Room and Board. In accordance with 42 CFR §441.310(a)(2), FFP is not claimed for the cost of room and board except when: (a) provided as part of respite services in a facility approved by the State that is not a private residence or (b) claimed as a portion of the rent and food that may be reasonably attributed to an unrelated caregiver who resides in the same household as the participant, as provided in Appendix I.
Access to Services. The State does not limit or restrict participant access to waiver services except as provided in Appendix C.
Free Choice of Provider. In accordance with 42 CFR §431.151, a participant may select any willing and qualified provider to furnish waiver services included in the service plan unless the State has received approval to limit the number of providers under the provisions of §1915(b) or another provision of the Act.
FFP Limitation. In accordance with 42 CFR §433 Subpart D, FFP is not claimed for services when another third-party (e.g., another third party health insurer or other federal or state program) is legally liable and responsible for the provision and payment of the service. FFP also may not be claimed for services that are available without charge, or as free care to the community. Services will not be considered to be without charge, or free care, when (1) the provider establishes a fee schedule for each service available and (2) collects insurance information from all those served (Medicaid, and non-Medicaid), and bills other legally liable third party insurers. Alternatively, if a provider certifies that a particular legally liable third party insurer does not pay for the service(s), the provider may not generate further bills for that insurer for that annual period.
Fair Hearing: The State provides the opportunity to request a Fair Hearing under 42 CFR §431 Subpart E, to individuals: (a) who are not given the choice of home and community-based waiver services as an alternative to institutional level of care specified for this waiver; (b) who are denied the service(s) of their choice or the provider(s) of their choice; or (c) whose services are denied, suspended, reduced or terminated. Appendix F specifies the State's procedures to provide individuals the opportunity to request a Fair Hearing, including providing notice of action as required in 42 CFR §431.210.
Quality Improvement. The State operates a formal, comprehensive system to ensure that the waiver meets the assurances and other requirements contained in this application. Through an ongoing process of discovery, remediation and improvement, the State assures the health and welfare of participants by monitoring: (a) level of care determinations; (b) individual plans and services delivery; (c) provider qualifications; (d) participant health and welfare; (e) financial oversight and (f) administrative oversight of the waiver. The State further assures that all problems identified through its discovery processes are addressed in an appropriate and timely manner, consistent with the severity and nature of the problem. During the period that the waiver is in effect, the State will implement the Quality Improvement Strategy specified in Appendix H.
Notice to Tribal Governments. The State assures that it has notified in writing all federally-recognized Tribal Governments that maintain a primary office and/or majority population within the State of the State's intent to submit a Medicaid waiver request or renewal request to CMS at least 60 days before the anticipated submission date is provided by Presidential Executive Order 13175 of November 6, 2000. Evidence of the applicable notice is available through the Medicaid Agency.
Limited English Proficient Persons. The State assures that it provides meaningful access to waiver services by Limited English Proficient persons in accordance with: (a) Presidential Executive Order 13166 of August 11, 2000 (65 FR 50121) and (b) Department of Health and Human Services "Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons" (68 FR 47311 - August 8, 2003). Appendix B describes how the State assures meaningful access to waiver services by Limited English Proficient persons.
State Medicaid Director or Designee
Specify the transition plan for the waiver:
State Line of Authority for Waiver Operation. Specify the state line of authority for the operation of the waiver (select one):
Specify the Medicaid agency division/unit that has line authority for the operation of the waiver program (select one):
In accordance with 42 CFR §431.10, the Medicaid agency exercises administrative discretion in the administration and supervision of the waiver and issues policies, rules and regulations related to the waiver. The interagency agreement or memorandum of understanding that sets forth the authority and arrangements for this policy is available through the Medicaid agency to CMS upon request. (Complete item A-2-b).
Oversight of Performance.
Role of Local/Regional Non-State Entities. Indicate whether local or regional non-state entities perform waiver operational and administrative functions and, if so, specify the type of entity (Select One):
Function | Medicaid Agency | Contracted Entity |
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Participant waiver enrollment | ||
Waiver enrollment managed against approved limits | ||
Waiver expenditures managed against approved levels | ||
Level of care evaluation | ||
Review of Participant service plans | ||
Prior authorization of waiver services | ||
Utilization management | ||
Qualified provider enrollment | ||
Execution of Medicaid provider agreements | ||
Establishment of a statewide rate methodology | ||
Rules, policies, procedures and information development governing the waiver program | ||
Quality assurance and quality improvement activities |
Performance Measures
Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Number and percent of required reports that were submitted by each ICA to the SMA per contract requirements. Numerator/Denominator: Number of each ICA's reports submitted per contract requirements over the number of required reports.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of required F/EA reports from each F/EA that were submitted by each F/EA to the SMA per contract requirements. Numerator/Denominator: Number of each F/EA's reports submitted per contract requirements over the number of required reports.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of new enrollees who had a level of care determination completed by the ADRC that indicates an eligible level of care prior to waiver enrollment. Numerator/Denominator: Number of new enrollees during designated time period who had an eligible LOC determined prior to start date over number of new enrollees during the designated time period.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of annual eligibility redeterminations that were conducted by the ICAs or ADRCs within 365 days of the participant's last LOC determination. Numerator/Denominator: Number of participants whose most recent screen is older than 365 days on the last day of the designated period over the number of participants on the final day of the designated period.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of initial service plans that were developed and approved in accordance with Waiver timelines (within 62 days of referral date). Numerator/Denominator: Number of service plans developed and approved within 62 days over the total number of service plans developed within the designated time period.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of participants who received services within the approved individual budget allocation, as verfied in a retrospective review. Numerator/Denominator: Number of participants reviewed who received services within the approved individual budget allocation over number of plans reviewed.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of screeners from each of the ICAs who are qualifed and certified to conduct level of care screenings using the Long-Term Care Functional Screen. Numerator/Denominator: Number of certified screeners from each of the ICAs over total number of IRIS screeners.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of IRIS screeners from each ICA who pass the Inter-Rater Reliability test. Numerator/Denominator: Number of IRIS screeners from each ICA who pass the IRRT over the total number of IRIS screeners from each ICA who take the IRRT.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of recent service plans (annual or updated plan) that were approved prior to implementation of services. Numerator/Denominator: Number of most recent service plans approved over of the number of service plans reviewed.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of new participant-hired workers for which each F/EA ensured that the provider had a signed Medicaid Provider agreement prior to furnishing services. Numerator/Denominator: Number of new participant-hired workers on each F/EA's provider registry that have signed Medicaid provider agreements over the number of new participant-hired workers on each F/EA's registry.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of new providers for which the TPA ensured that the provider had a signed Medicaid Provider agreement prior to furnishing services. Numerator/Denominator: Number of new providers on the TPA provider registry that have signed Medicaid provider agreements over the number of new providers on the TPA registry.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of required TPA reports that were submitted to the SMA per contract requirements. Numerator/Denominator: Number of TPA reports submitted per contract requirements over the number of required TPA reports.
Data Aggregation and Analysis:
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Responsible Party(check each that applies): | Frequency of data aggregation and analysis(check each that applies): |
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Target Group | Included | Target SubGroup | Minimum Age | Maximum Age | |
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Maximum Age Limit | No Maximum Age Limit | ||||
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Aged | |||||
Disabled (Physical) | |||||
Disabled (Other) | |||||
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Brain Injury | |||||
HIV/AIDS | |||||
Medically Fragile | |||||
Technology Dependent | |||||
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Autism | |||||
Developmental Disability | |||||
Intellectual Disability | |||||
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Mental Illness | |||||
Serious Emotional Disturbance | |||||
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The limit specified by the State is (select one)
The cost limit specified by the State is (select one):
The dollar amount (select one)
Answers provided in Appendix B-2-a indicate that you do not need to complete this section.
Waiver Year | Unduplicated Number of Participants |
Year 1 | |
Year 2 | |
Year 3 | |
Year 4 | |
Year 5 |
Waiver Year | Maximum Number of Participants Served At Any Point During the Year |
Year 1 | |
Year 2 | |
Year 3 | |
Year 4 | |
Year 5 |
Select one:
Answers provided in Appendix B-3-d indicate that you do not need to complete this section.
Select one:
Check each that applies:
Select one:
Select one:
In accordance with 42 CFR §441.303(e), Appendix B-5 must be completed when the State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217, as indicated in Appendix B-4. Post-eligibility applies only to the 42 CFR §435.217 group.
Use of Spousal Impoverishment Rules. Indicate whether spousal impoverishment rules are used to determine eligibility for the special home and community-based waiver group under 42 CFR §435.217:
In the case of a participant with a community spouse, the State elects to (select one):
Regular Post-Eligibility Treatment of Income: SSI State.
The State uses the post-eligibility rules at 42 CFR 435.726 for individuals who do not have a spouse or have a spouse who is not a community spouse as specified in §1924 of the Act. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the following allowances and expenses from the waiver participant's income:
Allowance for the needs of the waiver participant (select one):
Select one:
(select one):
Allowance for the spouse only (select one):
Specify the amount of the allowance (select one):
Allowance for the family (select one):
Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 §CFR 435.726:
Select one:
Regular Post-Eligibility Treatment of Income: 209(B) State.
Answers provided in Appendix B-4 indicate that you do not need to complete this section and therefore this section is not visible.
Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules
The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care if it determines the individual's eligibility under §1924 of the Act. There is deducted from the participant's monthly income a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the State Medicaid Plan. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).
Allowance for the personal needs of the waiver participant
(select one):
If the allowance for the personal needs of a waiver participant with a community spouse is different from the amount used for the individual's maintenance allowance under 42 CFR §435.726 or 42 CFR §435.735, explain why this amount is reasonable to meet the individual's maintenance needs in the community.
Select one:
Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 CFR §435.726:
Select one:
Regular Post-Eligibility Treatment of Income: §1634 State - 2014 through 2018.
Answers provided in Appendix B-5-a indicate that you do not need to complete this section and therefore this section is not visible.
Regular Post-Eligibility Treatment of Income: 209(B) State - 2014 through 2018.
Answers provided in Appendix B-5-a indicate that you do not need to complete this section and therefore this section is not visible.
Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules - 2014 through 2018.
The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care. There is deducted from the participant's monthly income a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the State Medicaid Plan. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).
Reasonable Indication of Need for Services. In order for an individual to be determined to need waiver services, an individual must require: (a) the provision of at least one waiver service, as documented in the service plan, and (b) the provision of waiver services at least monthly or, if the need for services is less than monthly, the participant requires regular monthly monitoring which must be documented in the service plan. Specify the State's policies concerning the reasonable indication of the need for services:
Minimum number of services.
The state demonstrates that it implements the processes and instrument(s) specified in its approved waiver for evaluating/reevaluating an applicant's/waiver participant's level of care consistent with level of care provided in a hospital, NF or ICF/IID.
Sub-assurance: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Number and percent of new enrollees who had a level of care determination indicating an eligible level of care prior to receipt of services. Numerator/Denominator: Number of new enrollees during designated time period who do not have a completed LTCFS on record over number of new enrollees during the designated time period.
Data Aggregation and Analysis:
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Sub-assurance: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Number and percent of waiver participants who received an annual redetermination of eligibility within 365 days of their of their last LOC evaluation. Numerator/Denominator: Number of participants whose most recent screen is older than 365 days on the last day of the designated period over the number of participants on the final day of the designated period.
Data Aggregation and Analysis:
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Sub-assurance: The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant level of care.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Responsible Party(check each that applies): | Frequency of data aggregation and analysis(check each that applies): |
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Service Type | Service | ![]() | ![]() |
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Statutory Service | Adult Day Care | ||
Statutory Service | Daily Living Skills Training | ||
Statutory Service | IRIS Consultant Services | ||
Statutory Service | Live-in Caregiver (42 CFR §441.303(f)(8)) | ||
Statutory Service | Prevocational Services | ||
Statutory Service | Respite | ||
Statutory Service | Supported Employment | ||
Extended State Plan Service | Nursing Services | ||
Supports for Participant Direction | Fiscal / Employer Agent Services | ||
Other Service | 1-2 Bed Adult Family Home | ||
Other Service | 3-4 Bed Adult Family Home | ||
Other Service | Adaptive Aids | ||
Other Service | CBRF | ||
Other Service | Communication Aids Vendors/Interpreter Services | ||
Other Service | Consumer Education and Training | ||
Other Service | Counseling and Therapeutic Services | ||
Other Service | Customized Goods and Services | ||
Other Service | Day Services | ||
Other Service | Home Delivered Meals | ||
Other Service | Home Modification | ||
Other Service | Housing Counseling | ||
Other Service | Personal Emergency Response System | ||
Other Service | Relocation - Housing Start Up and Related Utility Costs | ||
Other Service | Residential Care Apartment Complex | ||
Other Service | Specialized Medical Equipment and Supplies | ||
Other Service | Specialized Transportation 2 | ||
Other Service | Specialized Transportation | ||
Other Service | Support Broker | ||
Other Service | Supportive Home Care | ||
Other Service | Vocational Futures Planning |
Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
The waiver provides for participant direction of services as specified in Appendix E. Indicate whether the waiver includes the following supports or other supports for participant direction.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
|
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
|
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
|
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Appendix C: Participant ServicesC-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.
HCBS Taxonomy:
Service Delivery Method (check each that applies): Specify whether the service may be provided by (check each that applies):
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Delivery of Case Management Services.
Criminal History and/or Background Investigations.
Abuse Registry Screening.
Services in Facilities Subject to §1616(e) of the Social Security Act. Select one:
Facility Type | ![]() |
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1 to 4 Bed Adult Family Homes | |
Community Based Residential Facility (CBRF) | |
Residential Care Apartment Complex (RCAC) |
Appendix C: Participant ServicesC-2: Facility Specifications
Scope of Facility Sandards. For this facility type, please specify whether the State's standards address the following topics (check each that applies):
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Appendix C: Participant ServicesC-2: Facility Specifications
Scope of Facility Sandards. For this facility type, please specify whether the State's standards address the following topics (check each that applies):
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Appendix C: Participant ServicesC-2: Facility Specifications
Scope of Facility Sandards. For this facility type, please specify whether the State's standards address the following topics (check each that applies):
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Provision of Personal Care or Similar Services by Legally Responsible Individuals. A legally responsible individual is any person who has a duty under State law to care for another person and typically includes: (a) the parent (biological or adoptive) of a minor child or the guardian of a minor child who must provide care to the child or (b) a spouse of a waiver participant. Except at the option of the State and under extraordinary circumstances specified by the State, payment may not be made to a legally responsible individual for the provision of personal care or similar services that the legally responsible individual would ordinarily perform or be responsible to perform on behalf of a waiver participant. Select one:
Other State Policies Concerning Payment for Waiver Services Furnished by Relatives/Legal Guardians. Specify State policies concerning making payment to relatives/legal guardians for the provision of waiver services over and above the policies addressed in Item C-2-d. Select one:
Open Enrollment of Providers.
The state demonstrates that it has designed and implemented an adequate system for assuring that all waiver services are provided by qualified providers.
Sub-Assurance: The State verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other standards prior to their furnishing waiver services.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Number and percent of new providers that meet required licensure or certification standards prior to furnishing waiver services, as verified by the TPA. Numerator/Denominator: Number of new licensed/certified providers that hold the required licensure/certificate for the service(s) being provided over the total number of new providers.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of providers who continue to meet required licensure or certification standards as confirmed by the TPA every four years. Numerator/Denominator: Number of providers with licensure/certification confirmed over the number of providers requiring their licensure/certification to be confirmed.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of licensed/certified providers employed directly by the participant with current completed criminal background and caregiver registry checks. Numerator/Denominator: The number of licensed/certified providers employed directly by the participant for whom each F/EA has completed current criminal background and caregiver registry checks over the number of providers.
Data Aggregation and Analysis:
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Sub-Assurance: The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements.
For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Number and percent of non-licensed/non-certified particpant-hired workers with current criminal background and caregiver registry checks. Numerator/Denominator: The number of non-licensed/non-certified. Participant-Hired Workers for whom the F/EA has completed criminal background and caregiver registry checks over the number of providers.
Data Aggregation and Analysis:
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Sub-Assurance: The State implements its policies and procedures for verifying that provider training is conducted in accordance with state requirements and the approved waiver.
For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Responsible Party(check each that applies): | Frequency of data aggregation and analysis(check each that applies): |
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Section C-3 'Service Specifications' is incorporated into Section C-1 'Waiver Services.'
Additional Limits on Amount of Waiver Services. Indicate whether the waiver employs any of the following additional limits on the amount of waiver services (select one).
When a limit is employed, specify: (a) the waiver services to which the limit applies; (b) the basis of the limit, including its basis in historical expenditure/utilization patterns and, as applicable, the processes and methodologies that are used to determine the amount of the limit to which a participant's services are subject; (c) how the limit will be adjusted over the course of the waiver period; (d) provisions for adjusting or making exceptions to the limit based on participant health and welfare needs or other factors specified by the state; (e) the safeguards that are in effect when the amount of the limit is insufficient to meet a participant's needs; (f) how participants are notified of the amount of the limit. (check each that applies)
Description of the settings and how they meet federal HCB Settings requirements, at the time of submission and in the future.
Description of the means by which the state Medicaid agency ascertains that all waiver settings meet federal HCB Setting requirements, at the time of this submission and ongoing.
The state demonstrates it has designed and implemented an effective system for reviewing the adequacy of service plans for waiver participants.
Sub-assurance: Service plans address all participants assessed needs (including health and safety risk factors) and personal goals, either by the provision of waiver services or through other means.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Number and percent of participants with service plans that address participant needs as indicated by the Long-Term Care Functional Screen. Numerator/Denominator: Number of plans reviewed that addressed participant needs over the number of plans reviewed.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of participants whose identified health and safety risks are addressed in their service plan. Numerator/Denominator: Number of participants reviewed who have service plans with identified health and safety risks that are addressed over the number of service plans reviewed with identified health and safety risks.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of service plans that address participant identified outcomes/goals. Numerator/Denominator: Number of plans that address participant identified outcomes over the number of plans reviewed.
Data Aggregation and Analysis:
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Sub-assurance: The State monitors service plan development in accordance with its policies and procedures.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Number and percent of service plans that were developed in consultation with qualified IRIS staff. Numerator/Denominator: Number of service plans that were developed in consultation with qualified IRIS staff over the total number of service plans reviewed.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of initial service plans that were developed and approved in accordance with Waiver timelines (within 62 days of the referral date). Numerator/Denominator: Number of initial service plans that were developed within 62 days of the referral date over the total number of service plans developed within the designated time period.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of most recent service plans that were signed by the participant or legal representative. Numerator/Denominator: Number of current service plans that were signed by the participant or legal representative over the number of service plans reviewed.
Data Aggregation and Analysis:
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Sub-assurance: Service plans are updated/revised at least annually or when warranted by changes in the waiver participants needs.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Number and percent of participant service plans that were reviewed/updated annually. Numerator/Denominator: Number of service plans with a timely annual review over the number of service plans requiring annual review during the designated time period.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of participant service plans that were reviewed/updated when warranted. Numerator/Denominator: Number of service plans reviewed/updated when warranted over the number of participant service plans reviewed in which changing needs requiring the service plan to be reviewed//updated were identified.
Data Aggregation and Analysis:
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Sub-assurance: Services are delivered in accordance with the service plan, including the type, scope, amount, duration and frequency specified in the service plan.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Number and percent of participants who received services within the approved individual budget. Numerator/Denominator: Number of participants reviewed who reported claims paid were under the current approved individual budget during the designated time period over the total number of participants reviewed.
Data Aggregation and Analysis:
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Sub-assurance: Participants are afforded choice: Between waiver services and institutional care; and between/among waiver services and providers.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Number and percent of participants that have a current signed choice form that specifies choice was offered between institutional care and waiver services. N/D: Number of service plans reviewed with a signed signature page on the current service plan or choice form that indicates choice was offered between institutional care and waiver services over the total number of service plans reviewed.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of participants that have a current signed choice form that specifies choice was offered among waiver services and providers. Numerator/Denominator: Number of signed service plans or signed choice forms reviewed that indicates choice was offered among waiver services and providers over the total number of records reviewed.
Data Aggregation and Analysis:
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Responsible Party(check each that applies): | Frequency of data aggregation and analysis(check each that applies): |
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Applicability (from Application Section 3, Components of the Waiver Request):
CMS urges states to afford all waiver participants the opportunity to direct their services. Participant direction of services includes the participant exercising decision-making authority over workers who provide services, a participant-managed budget or both. CMS will confer the Independence Plus designation when the waiver evidences a strong commitment to participant direction.
Indicate whether Independence Plus designation is requested (select one):
Description of Participant Direction.
Participant Direction Opportunities. Specify the participant direction opportunities that are available in the waiver. Select one:
Availability of Participant Direction by Type of Living Arrangement. Check each that applies:
Election of Participant Direction.
Information Furnished to Participant.
Participant Direction by a Representative.
Specify the representatives who may direct waiver services: (check each that applies):
Participant-Directed Services.
Waiver Service | Employer Authority | Budget Authority |
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Respite | ||
3-4 Bed Adult Family Home | ||
Supported Employment | ||
1-2 Bed Adult Family Home | ||
Nursing Services | ||
Vocational Futures Planning | ||
Communication Aids Vendors/Interpreter Services | ||
Customized Goods and Services | ||
Home Delivered Meals | ||
Housing Counseling | ||
Home Modification | ||
IRIS Consultant Services | ||
Personal Emergency Response System | ||
Fiscal / Employer Agent Services | ||
Adult Day Care | ||
Specialized Medical Equipment and Supplies | ||
Specialized Transportation 2 | ||
Relocation - Housing Start Up and Related Utility Costs | ||
Support Broker | ||
Supportive Home Care | ||
Consumer Education and Training | ||
Specialized Transportation | ||
Counseling and Therapeutic Services | ||
Adaptive Aids | ||
Daily Living Skills Training | ||
Day Services | ||
CBRF | ||
Prevocational Services | ||
Live-in Caregiver (42 CFR §441.303(f)(8)) | ||
Residential Care Apartment Complex |
Financial Management Services. Except in certain circumstances, financial management services are mandatory and integral to participant direction. A governmental entity and/or another third-party entity must perform necessary financial transactions on behalf of the waiver participant. Select one:
Specify whether governmental and/or private entities furnish these services. Check each that applies:
Provision of Financial Management Services. Financial management services (FMS) may be furnished as a waiver service or as an administrative activity. Select one:
Provide the following information
Types of Entities:
Payment for FMS.
Scope of FMS. Specify the scope of the supports that FMS entities provide (check each that applies):
Supports furnished when the participant is the employer of direct support workers:
Supports furnished when the participant exercises budget authority:
Additional functions/activities:
Oversight of FMS Entities.
Information and Assistance in Support of Participant Direction. In addition to financial management services, participant direction is facilitated when information and assistance are available to support participants in managing their services. These supports may be furnished by one or more entities, provided that there is no duplication. Specify the payment authority (or authorities) under which these supports are furnished and, where required, provide the additional information requested (check each that applies):
Participant-Directed Waiver Service | Information and Assistance Provided through this Waiver Service Coverage |
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Respite | |
3-4 Bed Adult Family Home | |
Supported Employment | |
1-2 Bed Adult Family Home | |
Nursing Services | |
Vocational Futures Planning | |
Communication Aids Vendors/Interpreter Services | |
Customized Goods and Services | |
Home Delivered Meals | |
Housing Counseling | |
Home Modification | |
IRIS Consultant Services | |
Personal Emergency Response System | |
Fiscal / Employer Agent Services | |
Adult Day Care | |
Specialized Medical Equipment and Supplies | |
Specialized Transportation 2 | |
Relocation - Housing Start Up and Related Utility Costs | |
Support Broker | |
Supportive Home Care | |
Consumer Education and Training | |
Specialized Transportation | |
Counseling and Therapeutic Services | |
Adaptive Aids | |
Daily Living Skills Training | |
Day Services | |
CBRF | |
Prevocational Services | |
Live-in Caregiver (42 CFR §441.303(f)(8)) | |
Residential Care Apartment Complex |
Independent Advocacy (select one).
Voluntary Termination of Participant Direction.
Involuntary Termination of Participant Direction.
Goals for Participant Direction. In the following table, provide the State's goals for each year that the waiver is in effect for the unduplicated number of waiver participants who are expected to elect each applicable participant direction opportunity. Annually, the State will report to CMS the number of participants who elect to direct their waiver services.
Employer Authority Only | Budget Authority Only or Budget Authority in Combination with Employer Authority | |
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Waiver Year | Number of Participants | Number of Participants |
Year 1 | ||
Year 2 | ||
Year 3 | ||
Year 4 | ||
Year 5 |
Participant - Employer Authority Complete when the waiver offers the employer authority opportunity as indicated in Item E-1-b:
Participant Employer Status. Specify the participant's employer status under the waiver. Select one or both:
Participant Decision Making Authority. The participant (or the participant's representative) has decision making authority over workers who provide waiver services. Select one or more decision making authorities that participants exercise:
Participant - Budget Authority Complete when the waiver offers the budget authority opportunity as indicated in Item E-1-b:
Participant Decision Making Authority. When the participant has budget authority, indicate the decision-making authority that the participant may exercise over the budget. Select one or more:
Participant - Budget Authority
Participant-Directed Budget
Participant - Budget Authority
Informing Participant of Budget Amount.
Participant - Budget Authority
Participant Exercise of Budget Flexibility. Select one:
Participant - Budget Authority
Expenditure Safeguards.
The State provides an opportunity to request a Fair Hearing under 42 CFR Part 431, Subpart E to individuals: (a) who are not given the choice of home and community-based services as an alternative to the institutional care specified in Item 1-F of the request; (b) are denied the service(s) of their choice or the provider(s) of their choice; or, (c) whose services are denied, suspended, reduced or terminated. The State provides notice of action as required in 42 CFR §431.210.
Procedures for Offering Opportunity to Request a Fair Hearing.
Availability of Additional Dispute Resolution Process. Indicate whether the State operates another dispute resolution process that offers participants the opportunity to appeal decisions that adversely affect their services while preserving their right to a Fair Hearing. Select one:
Description of Additional Dispute Resolution Process.
Operation of Grievance/Complaint System. Select one:
Operational Responsibility.
Description of System.
Critical Event or Incident Reporting and Management Process.
State Critical Event or Incident Reporting Requirements.
Participant Training and Education.
Responsibility for Review of and Response to Critical Events or Incidents.
Responsibility for Oversight of Critical Incidents and Events.
Use of Restraints. (Select one): (For waiver actions submitted before March 2014, responses in Appendix G-2-a will display information for both restraints and seclusion. For most waiver actions submitted after March 2014, responses regarding seclusion appear in Appendix G-2-c.)
Safeguards Concerning the Use of Restraints.
State Oversight Responsibility.
Use of Restrictive Interventions. (Select one):
Safeguards Concerning the Use of Restrictive Interventions.
State Oversight Responsibility.
Use of Seclusion. (Select one): (This section will be blank for waivers submitted before Appendix G-2-c was added to WMS in March 2014, and responses for seclusion will display in Appendix G-2-a combined with information on restraints.)
Safeguards Concerning the Use of Seclusion.
State Oversight Responsibility.
This Appendix must be completed when waiver services are furnished to participants who are served in licensed or unlicensed living arrangements where a provider has round-the-clock responsibility for the health and welfare of residents. The Appendix does not need to be completed when waiver participants are served exclusively in their own personal residences or in the home of a family member.
Applicability. Select one:
Medication Management and Follow-Up
Responsibility.
Methods of State Oversight and Follow-Up.
Medication Administration by Waiver Providers
Provider Administration of Medications. Select one:
State Policy.
Medication Error Reporting. Select one of the following:
State Oversight Responsibility.
Sub-assurance: The state demonstrates on an ongoing basis that it identifies, addresses and seeks to prevent instancesof abuse, neglect, exploitation and unexplained death. (Performance measures in this sub-assurance include all Appendix G performance measures for waiver actions submitted before June 1, 2014.)
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Number and percent of participant records reviewed where the participant or legal representative received information/education about how to report abuse, neglect, exploitation and other critical incidents. Numerator/Denominator: Number of records where the legal representative received information about critical incidents over the number of records reviewed.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of critical incidents reports that indicated that the incident was addressed in a manner that ensures the health and safety of the participant. Numerator/Denominator: Number of critical incidents reported in which the incident was addressed over the number of incidents reported during the time period.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of participant deaths reviewed by the mortality review committee. Numerator/Denominator: Number of participant deaths reviewed by the mortality review committee over the number of deaths occuring during the designated time period.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of restrictive measures that were applied for and reviewed according to the restrictive measures application application protocol. Numerator/Denominator: Number of restrictive measures reviewed according to protocol over the number of restrictive measures applications submitted during time period.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of participant records reviewed that indicate an incident report was completed and submitted for each reportable incident. Numerator/Denominator: Number of participant records reviewed for which an incident report was completed and submitted for each incident over the number of participant records reviewed for which there was at least one incident discovered.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of restrictive measures as identified in the participant record review that followed the WI Restrictive Measures protocol. Numerator/Denominator: Number of restrictive measures in place as identified in the participant record review that followed the restrictive measures protocol over the number of restrictive measures identified in the participant record review.
Data Aggregation and Analysis:
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Sub-assurance: The state demonstrates that an incident management system is in place that effectively resolves those incidents and prevents further similar incidents to the extent possible.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Sub-assurance: The state policies and procedures for the use or prohibition of restrictive interventions (including restraints and seclusion) are followed.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Sub-assurance: The state establishes overall health care standards and monitors those standards based on the responsibility of the service provider as stated in the approved waiver.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Responsible Party(check each that applies): | Frequency of data aggregation and analysis(check each that applies): |
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Under §1915(c) of the Social Security Act and 42 CFR §441.302, the approval of an HCBS waiver requires that CMS determine that the State has made satisfactory assurances concerning the protection of participant health and welfare, financial accountability and other elements of waiver operations. Renewal of an existing waiver is contingent upon review by CMS and a finding by CMS that the assurances have been met. By completing the HCBS waiver application, the State specifies how it has designed the waiver’s critical processes, structures and operational features in order to meet these assurances.
CMS recognizes that a state’s waiver Quality Improvement Strategy may vary depending on the nature of the waiver target population, the services offered, and the waiver’s relationship to other public programs, and will extend beyond regulatory requirements. However, for the purpose of this application, the State is expected to have, at the minimum, systems in place to measure and improve its own performance in meeting six specific waiver assurances and requirements.
It may be more efficient and effective for a Quality Improvement Strategy to span multiple waivers and other long-term care services. CMS recognizes the value of this approach and will ask the state to identify other waiver programs and long-term care services that are addressed in the Quality Improvement Strategy.
The Quality Improvement Strategy that will be in effect during the period of the approved waiver is described throughout the waiver in the appendices corresponding to the statutory assurances and sub-assurances. Other documents cited must be available to CMS upon request through the Medicaid agency or the operating agency (if appropriate).
In the QIS discovery and remediation sections throughout the application (located in Appendices A, B, C, D, G, and I) , a state spells out:
In Appendix H of the application, a State describes (1) the system improvement activities followed in response to aggregated, analyzed discovery and remediation information collected on each of the assurances; (2) the correspondent roles/responsibilities of those conducting assessing and prioritizing improving system corrections and improvements; and (3) the processes the state will follow to continuously assess the effectiveness of the OIS and revise it as necessary and appropriate.
If the State's Quality Improvement Strategy is not fully developed at the time the waiver application is submitted, the state may provide a work plan to fully develop its Quality Improvement Strategy, including the specific tasks the State plans to undertake during the period the waiver is in effect, the major milestones associated with these tasks, and the entity (or entities) responsible for the completion of these tasks.
When the Quality Improvement Strategy spans more than one waiver and/or other types of long-term care services under the Medicaid State plan, specify the control numbers for the other waiver programs and/or identify the other long-term services that are addressed in the Quality Improvement Strategy. In instances when the QIS spans more than one waiver, the State must be able to stratify information that is related to each approved waiver program. Unless the State has requested and received approval from CMS for the consolidation of multiple waivers for the purpose of reporting, then the State must stratify information that is related to each approved waiver program, i.e., employ a representative sample for each waiver.
System Improvements
Responsible Party(check each that applies): | Frequency of Monitoring and Analysis(check each that applies): |
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System Design Changes
Financial Integrity.
Sub-assurance: The State provides evidence that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver and only for services rendered. (Performance measures in this sub-assurance include all Appendix I performance measures for waiver actions submitted before June 1, 2014.)
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Number and percent of waiver service claims paid that were authorized in the participant's service plan. Numerator/Denominator: Number of claims submitted that are on the service plan over the total number of claims submitted during the designated period.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of waiver service claims paid that were coded correctly. Numerator/Denominator: Number of claims coded correctly over the number of claims processed during the review period.
Data Aggregation and Analysis:
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Performance Measure:
Number and percent of claims held that were resolved prior to payment. Numerator/Denominator: Number of claims pended that were resolved prior to payment over the total number of claims pended during the period.
Data Aggregation and Analysis:
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Performance Measure:
The number and percent of TPA monthly encounter data submissions that were accepted and certified timely. Numerator/Denominator: Number of TPA monthly submissions accepted and certified timely over the total number of submissions.
Data Aggregation and Analysis:
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Sub-assurance: The state provides evidence that rates remain consistent with the approved rate methodology throughout the five year waiver cycle.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Responsible Party(check each that applies): | Frequency of data aggregation and analysis(check each that applies): |
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Rate Determination Methods.
Flow of Billings.
Certifying Public Expenditures (select one):
Select at least one:
Billing Validation Process.
Billing and Claims Record Maintenance Requirement. Records documenting the audit trail of adjudicated claims (including supporting documentation) are maintained by the Medicaid agency, the operating agency (if applicable), and providers of waiver services for a minimum period of 3 years as required in 45 CFR §92.42.
Method of payments -- MMIS (select one):
Direct payment. In addition to providing that the Medicaid agency makes payments directly to providers of waiver services, payments for waiver services are made utilizing one or more of the following arrangements (select at least one):
Supplemental or Enhanced Payments. Section 1902(a)(30) requires that payments for services be consistent with efficiency, economy, and quality of care. Section 1903(a)(1) provides for Federal financial participation to States for expenditures for services under an approved State plan/waiver. Specify whether supplemental or enhanced payments are made. Select one:
Payments to State or Local Government Providers. Specify whether State or local government providers receive payment for the provision of waiver services.
Amount of Payment to State or Local Government Providers.
Specify whether any State or local government provider receives payments (including regular and any supplemental payments) that in the aggregate exceed its reasonable costs of providing waiver services and, if so, whether and how the State recoups the excess and returns the Federal share of the excess to CMS on the quarterly expenditure report. Select one:
Provider Retention of Payments. Section 1903(a)(1) provides that Federal matching funds are only available for expenditures made by states for services under the approved waiver. Select one:
Additional Payment Arrangements
Voluntary Reassignment of Payments to a Governmental Agency. Select one:
Organized Health Care Delivery System. Select one:
Contracts with MCOs, PIHPs or PAHPs. Select one:
State Level Source(s) of the Non-Federal Share of Computable Waiver Costs. Specify the State source or sources of the non-federal share of computable waiver costs. Select at least one:
Local Government or Other Source(s) of the Non-Federal Share of Computable Waiver Costs. Specify the source or sources of the non-federal share of computable waiver costs that are not from state sources. Select One:
Information Concerning Certain Sources of Funds. Indicate whether any of the funds listed in Items I-4-a or I-4-b that make up the non-federal share of computable waiver costs come from the following sources: (a) health care-related taxes or fees; (b) provider-related donations; and/or, (c) federal funds. Select one:
Services Furnished in Residential Settings. Select one:
Reimbursement for the Rent and Food Expenses of an Unrelated Live-In Personal Caregiver. Select one:
Co-Payment Requirements. Specify whether the State imposes a co-payment or similar charge upon waiver participants for waiver services. These charges are calculated per service and have the effect of reducing the total computable claim for federal financial participation. Select one:
Co-Pay Arrangement.
Specify the types of co-pay arrangements that are imposed on waiver participants (check each that applies):
Charges Associated with the Provision of Waiver Services (if any are checked, complete Items I-7-a-ii through I-7-a-iv):
Co-Payment Requirements.
Participants Subject to Co-pay Charges for Waiver Services.
Answers provided in Appendix I-7-a indicate that you do not need to complete this section.
Co-Payment Requirements.
Amount of Co-Pay Charges for Waiver Services.
Answers provided in Appendix I-7-a indicate that you do not need to complete this section.
Co-Payment Requirements.
Cumulative Maximum Charges.
Answers provided in Appendix I-7-a indicate that you do not need to complete this section.
Other State Requirement for Cost Sharing. Specify whether the State imposes a premium, enrollment fee or similar cost sharing on waiver participants. Select one:
Nursing Facility
Col. 1 | Col. 2 | Col. 3 | Col. 4 | Col. 5 | Col. 6 | Col. 7 | Col. 8 |
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Year | Factor D | Factor D' | Total: D+D' | Factor G | Factor G' | Total: G+G' | Difference (Col 7 less Column4) |
1 | 13340.06 | 24172.59 | 32083.27 | 7910.68 | |||
2 | 11652.53 | 32567.56 | 38487.90 | 5920.34 | |||
3 | 13510.85 | 37437.79 | 44304.57 | 6866.78 | |||
4 | 13974.71 | 38477.28 | 45920.42 | 7443.14 | |||
5 | 18263.71 | 44530.31 | 49826.86 | 5296.55 |
Number Of Unduplicated Participants Served. Enter the total number of unduplicated participants from Item B-3-a who will be served each year that the waiver is in operation. When the waiver serves individuals under more than one level of care, specify the number of unduplicated participants for each level of care:
Waiver Year | Total Unduplicated Number of Participants (from Item B-3-a) | Distribution of Unduplicated Participants by Level of Care (if applicable) | |||
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Level of Care: | |||||
Nursing Facility | |||||
Year 1 | 2548 | ||||
Year 2 | 5146 | ||||
Year 3 | 7397 | ||||
Year 4 | 7118 | ||||
Year 5 | 7688 |
Average Length of Stay.
Derivation of Estimates for Each Factor. Provide a narrative description for the derivation of the estimates of the following factors.
Component management for waiver services. If the service(s) below includes two or more discrete services that are reimbursed separately, or is a bundled service, each component of the service must be listed. Select “manage components” to add these components.
Waiver Services | ![]() |
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Adult Day Care | |
Daily Living Skills Training | |
IRIS Consultant Services | |
Live-in Caregiver (42 CFR §441.303(f)(8)) | |
Prevocational Services | |
Respite | |
Supported Employment | |
Nursing Services | |
Fiscal / Employer Agent Services | |
1-2 Bed Adult Family Home | |
3-4 Bed Adult Family Home | |
Adaptive Aids | |
CBRF | |
Communication Aids Vendors/Interpreter Services | |
Consumer Education and Training | |
Counseling and Therapeutic Services | |
Customized Goods and Services | |
Day Services | |
Home Delivered Meals | |
Home Modification | |
Housing Counseling | |
Personal Emergency Response System | |
Relocation - Housing Start Up and Related Utility Costs | |
Residential Care Apartment Complex | |
Specialized Medical Equipment and Supplies | |
Specialized Transportation 2 | |
Specialized Transportation | |
Support Broker | |
Supportive Home Care | |
Vocational Futures Planning |
Estimate of Factor D.
ii. Concurrent §1915(b)/§1915(c) Waivers, or other authorities utilizing capitated arrangements (i.e., 1915(a), 1932(a), Section 1937).
Waiver Service/ Component | Capi-tation | Unit | # Users | Avg. Units Per User | Avg. Cost/ Unit | Component Cost | Total Cost | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Adult Day Care Total: | 283453.29 | ||||||||||||||||||||||
Adult Day Care | 283453.29 | ||||||||||||||||||||||
Daily Living Skills Training Total: | 70227.74 | ||||||||||||||||||||||
Daily Living Skills Training | 70227.74 | ||||||||||||||||||||||
IRIS Consultant Services Total: | 0.00 | ||||||||||||||||||||||
IRIS Consultant Services | 0.00 | ||||||||||||||||||||||
Live-in Caregiver (42 CFR §441.303(f)(8)) Total: | 74576.80 | ||||||||||||||||||||||
Live-in Caregiver (42 CFR §441.303(f)(8)) | 74576.80 | ||||||||||||||||||||||
Prevocational Services Total: | 22895.50 | ||||||||||||||||||||||
Prevocational Services | 22895.50 | ||||||||||||||||||||||
Respite Total: | 517269.19 | ||||||||||||||||||||||
Respite | 517269.19 | ||||||||||||||||||||||
Supported Employment Total: | 2789.28 | ||||||||||||||||||||||
Supported Employment | 2789.28 | ||||||||||||||||||||||
Nursing Services Total: | 497596.68 | ||||||||||||||||||||||
Nursing Services | 497596.68 | ||||||||||||||||||||||
Fiscal / Employer Agent Services Total: | 0.00 | ||||||||||||||||||||||
Fiscal / Employer Agent Services | 0.00 | ||||||||||||||||||||||
1-2 Bed Adult Family Home Total: | 28418.00 | ||||||||||||||||||||||
1-2 Bed Adult Family Home | 28418.00 | ||||||||||||||||||||||
3-4 Bed Adult Family Home Total: | 100364.50 | ||||||||||||||||||||||
3-4 Bed Adult Family Home | 100364.50 | ||||||||||||||||||||||
Adaptive Aids Total: | 1168998.10 | ||||||||||||||||||||||
Adaptive Aids | 1168998.10 | ||||||||||||||||||||||
CBRF Total: | 695683.30 | ||||||||||||||||||||||
CBRF | 695683.30 | ||||||||||||||||||||||
Communication Aids Vendors/Interpreter Services Total: | 124560.37 | ||||||||||||||||||||||
Communication Aids Vendors/Interpreter Services | 124560.37 | ||||||||||||||||||||||
Consumer Education and Training Total: | 9730.05 | ||||||||||||||||||||||
Consumer Education and Training | 9730.05 | ||||||||||||||||||||||
Counseling and Therapeutic Services Total: | 369885.57 | ||||||||||||||||||||||
Counseling and Therapeutic Services | 369885.57 | ||||||||||||||||||||||
Customized Goods and Services Total: | 2393651.27 | ||||||||||||||||||||||
Customized Goods and Services | 2393651.27 | ||||||||||||||||||||||
Day Services Total: | 267140.08 | ||||||||||||||||||||||
Day Services | 267140.08 | ||||||||||||||||||||||
Home Delivered Meals Total: | 158406.25 | ||||||||||||||||||||||
Home Delivered Meals | 158406.25 | ||||||||||||||||||||||
Home Modification Total: | 604402.01 | ||||||||||||||||||||||
Home Modification | 604402.01 | ||||||||||||||||||||||
Housing Counseling Total: | 95629.11 | ||||||||||||||||||||||
Housing Counseling | 95629.11 | ||||||||||||||||||||||
Personal Emergency Response System Total: | 113579.84 | ||||||||||||||||||||||
Personal Emergency Response System | 113579.84 | ||||||||||||||||||||||
Relocation - Housing Start Up and Related Utility Costs Total: | 47067.55 | ||||||||||||||||||||||
Relocation - Housing Start Up and Related Utility Costs | 47067.55 | ||||||||||||||||||||||
Residential Care Apartment Complex Total: | 267701.40 | ||||||||||||||||||||||
Residential Care Apartment Complex | 267701.40 | ||||||||||||||||||||||
Specialized Medical Equipment and Supplies Total: | 73672.87 | ||||||||||||||||||||||
Specialized Medical Equipment and Supplies | 73672.87 | ||||||||||||||||||||||
Specialized Transportation 2 Total: | 212318.54 | ||||||||||||||||||||||
Specialized Transportation 2 | 212318.54 | ||||||||||||||||||||||
Specialized Transportation Total: | 673309.73 | ||||||||||||||||||||||
Specialized Transportation | 673309.73 | ||||||||||||||||||||||
Support Broker Total: | 150937.23 | ||||||||||||||||||||||
Support Broker | 150937.23 | ||||||||||||||||||||||
Supportive Home Care Total: | 24952550.99 | ||||||||||||||||||||||
Supportive Home Care | 24952550.99 | ||||||||||||||||||||||
Vocational Futures Planning Total: | 13657.43 | ||||||||||||||||||||||
Vocational Futures Planning | 13657.43 | ||||||||||||||||||||||
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Estimate of Factor D.
ii. Concurrent §1915(b)/§1915(c) Waivers, or other authorities utilizing capitated arrangements (i.e., 1915(a), 1932(a), Section 1937).
Waiver Service/ Component | Capi-tation | Unit | # Users | Avg. Units Per User | Avg. Cost/ Unit | Component Cost | Total Cost | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Adult Day Care Total: | 499961.36 | ||||||||||||||||||||||
Adult Day Care | 499961.36 | ||||||||||||||||||||||
Daily Living Skills Training Total: | 130084.14 | ||||||||||||||||||||||
Daily Living Skills Training | 130084.14 | ||||||||||||||||||||||
IRIS Consultant Services Total: | 0.00 | ||||||||||||||||||||||
IRIS Consultant Services | 0.00 | ||||||||||||||||||||||
Live-in Caregiver (42 CFR §441.303(f)(8)) Total: | 177028.65 | ||||||||||||||||||||||
Live-in Caregiver (42 CFR §441.303(f)(8)) | 177028.65 | ||||||||||||||||||||||
Prevocational Services Total: | 42409.36 | ||||||||||||||||||||||
Prevocational Services | 42409.36 | ||||||||||||||||||||||
Respite Total: | 909732.85 | ||||||||||||||||||||||
Respite | 909732.85 | ||||||||||||||||||||||
Supported Employment Total: | 5169.61 | ||||||||||||||||||||||
Supported Employment | 5169.62 | ||||||||||||||||||||||
Nursing Services Total: | 878623.20 | ||||||||||||||||||||||
Nursing Services | 878623.20 | ||||||||||||||||||||||
Fiscal / Employer Agent Services Total: | 0.00 | ||||||||||||||||||||||
Fiscal / Employer Agent Services | 0.00 | ||||||||||||||||||||||
1-2 Bed Adult Family Home Total: | 55725.36 | ||||||||||||||||||||||
1-2 Bed Adult Family Home | 55725.36 | ||||||||||||||||||||||
3-4 Bed Adult Family Home Total: | 185903.84 | ||||||||||||||||||||||
3-4 Bed Adult Family Home | 185903.84 | ||||||||||||||||||||||
Adaptive Aids Total: | 2063368.79 | ||||||||||||||||||||||
Adaptive Aids | 2063368.79 | ||||||||||||||||||||||
CBRF Total: | 1237099.42 | ||||||||||||||||||||||
CBRF | 1237099.42 | ||||||||||||||||||||||
Communication Aids Vendors/Interpreter Services Total: | 219406.32 | ||||||||||||||||||||||
Communication Aids Vendors/Interpreter Services | 219406.32 | ||||||||||||||||||||||
Consumer Education and Training Total: | 16971.32 | ||||||||||||||||||||||
Consumer Education and Training | 16971.32 | ||||||||||||||||||||||
Counseling and Therapeutic Services Total: | 650394.74 | ||||||||||||||||||||||
Counseling and Therapeutic Services | 650394.74 | ||||||||||||||||||||||
Customized Goods and Services Total: | 4216669.60 | ||||||||||||||||||||||
Customized Goods and Services | 4216669.60 | ||||||||||||||||||||||
Day Services Total: | 471962.28 | ||||||||||||||||||||||
Day Services | 471962.28 | ||||||||||||||||||||||
Home Delivered Meals Total: | 278275.30 | ||||||||||||||||||||||
Home Delivered Meals | 278275.30 | ||||||||||||||||||||||
Home Modification Total: | 1060561.74 | ||||||||||||||||||||||
Home Modification | 1060561.74 | ||||||||||||||||||||||
Housing Counseling Total: | 166766.60 | ||||||||||||||||||||||
Housing Counseling | 166766.60 | ||||||||||||||||||||||
Personal Emergency Response System Total: | 200221.72 | ||||||||||||||||||||||
Personal Emergency Response System | 200221.72 | ||||||||||||||||||||||
Relocation - Housing Start Up and Related Utility Costs Total: | 81995.35 | ||||||||||||||||||||||
Relocation - Housing Start Up and Related Utility Costs | 81995.35 | ||||||||||||||||||||||
Residential Care Apartment Complex Total: | 477737.57 | ||||||||||||||||||||||
Residential Care Apartment Complex | 477737.57 | ||||||||||||||||||||||
Specialized Medical Equipment and Supplies Total: | 130047.70 | ||||||||||||||||||||||
Specialized Medical Equipment and Supplies | 130047.70 | ||||||||||||||||||||||
Specialized Transportation 2 Total: | 374169.10 | ||||||||||||||||||||||
Specialized Transportation 2 | 374169.10 | ||||||||||||||||||||||
Specialized Transportation Total: | 1198645.25 | ||||||||||||||||||||||
Specialized Transportation | 1198645.25 | ||||||||||||||||||||||
Support Broker Total: | 263158.55 | ||||||||||||||||||||||
Support Broker | 263158.55 | ||||||||||||||||||||||
Supportive Home Care Total: | 43947384.47 | ||||||||||||||||||||||
Supportive Home Care | 43947384.47 | ||||||||||||||||||||||
Vocational Futures Planning Total: | 24428.20 | ||||||||||||||||||||||
Vocational Futures Planning | 24428.20 | ||||||||||||||||||||||
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Estimate of Factor D.
ii. Concurrent §1915(b)/§1915(c) Waivers, or other authorities utilizing capitated arrangements (i.e., 1915(a), 1932(a), Section 1937).
Waiver Service/ Component | Capi-tation | Unit | # Users | Avg. Units Per User | Avg. Cost/ Unit | Component Cost | Total Cost | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Adult Day Care Total: | 832845.10 | ||||||||||||||||||||||
Adult Day Care | 832845.10 | ||||||||||||||||||||||
Daily Living Skills Training Total: | 213122.34 | ||||||||||||||||||||||
Daily Living Skills Training | 213122.34 | ||||||||||||||||||||||
IRIS Consultant Services Total: | 0.00 | ||||||||||||||||||||||
IRIS Consultant Services | 0.00 | ||||||||||||||||||||||
Live-in Caregiver (42 CFR §441.303(f)(8)) Total: | 249003.00 | ||||||||||||||||||||||
Live-in Caregiver (42 CFR §441.303(f)(8)) | 249003.00 | ||||||||||||||||||||||
Prevocational Services Total: | 69498.66 | ||||||||||||||||||||||
Prevocational Services | 69498.66 | ||||||||||||||||||||||
Respite Total: | 1515451.11 | ||||||||||||||||||||||
Respite | 1515451.11 | ||||||||||||||||||||||
Supported Employment Total: | 8467.30 | ||||||||||||||||||||||
Supported Employment | 8467.30 | ||||||||||||||||||||||
Nursing Services Total: | 1460238.16 | ||||||||||||||||||||||
Nursing Services | 1460238.16 | ||||||||||||||||||||||
Fiscal / Employer Agent Services Total: | 0.00 | ||||||||||||||||||||||
Fiscal / Employer Agent Services | 0.00 | ||||||||||||||||||||||
1-2 Bed Adult Family Home Total: | 86233.80 | ||||||||||||||||||||||
1-2 Bed Adult Family Home | 86233.80 | ||||||||||||||||||||||
3-4 Bed Adult Family Home Total: | 304584.41 | ||||||||||||||||||||||
3-4 Bed Adult Family Home | 304584.41 | ||||||||||||||||||||||
Adaptive Aids Total: | 3441759.11 | ||||||||||||||||||||||
Adaptive Aids | 3441759.11 | ||||||||||||||||||||||
CBRF Total: | 2054913.17 | ||||||||||||||||||||||
CBRF | 2054913.17 | ||||||||||||||||||||||
Communication Aids Vendors/Interpreter Services Total: | 366340.00 | ||||||||||||||||||||||
Communication Aids Vendors/Interpreter Services | 366340.00 | ||||||||||||||||||||||
Consumer Education and Training Total: | 28316.31 | ||||||||||||||||||||||
Consumer Education and Training | 28316.31 | ||||||||||||||||||||||
Counseling and Therapeutic Services Total: | 1087644.25 | ||||||||||||||||||||||
Counseling and Therapeutic Services | 1087644.25 | ||||||||||||||||||||||
Customized Goods and Services Total: | 7032753.81 | ||||||||||||||||||||||
Customized Goods and Services | 7032753.81 | ||||||||||||||||||||||
Day Services Total: | 782382.62 | ||||||||||||||||||||||
Day Services | 782382.62 | ||||||||||||||||||||||
Home Delivered Meals Total: | 463457.80 | ||||||||||||||||||||||
Home Delivered Meals | 463457.80 | ||||||||||||||||||||||
Home Modification Total: | 1771143.00 | ||||||||||||||||||||||
Home Modification | 1771143.00 | ||||||||||||||||||||||
Housing Counseling Total: | 278883.27 | ||||||||||||||||||||||
Housing Counseling | 278883.27 | ||||||||||||||||||||||
Personal Emergency Response System Total: | 334058.47 | ||||||||||||||||||||||
Personal Emergency Response System | 334058.47 | ||||||||||||||||||||||
Relocation - Housing Start Up and Related Utility Costs Total: | 137192.24 | ||||||||||||||||||||||
Relocation - Housing Start Up and Related Utility Costs | 137192.24 | ||||||||||||||||||||||
Residential Care Apartment Complex Total: | 786542.53 | ||||||||||||||||||||||
Residential Care Apartment Complex | 786542.53 | ||||||||||||||||||||||
Specialized Medical Equipment and Supplies Total: | 218024.07 | ||||||||||||||||||||||
Specialized Medical Equipment and Supplies | 218024.07 | ||||||||||||||||||||||
Specialized Transportation 2 Total: | 623794.47 | ||||||||||||||||||||||
Specialized Transportation 2 | 623794.47 | ||||||||||||||||||||||
Specialized Transportation Total: | 1983643.00 | ||||||||||||||||||||||
Specialized Transportation | 1983643.00 | ||||||||||||||||||||||
Support Broker Total: | 434588.08 | ||||||||||||||||||||||
Support Broker | 434588.08 | ||||||||||||||||||||||
Supportive Home Care Total: | 73334885.65 | ||||||||||||||||||||||
Supportive Home Care | 73334885.65 | ||||||||||||||||||||||
Vocational Futures Planning Total: | 39993.10 | ||||||||||||||||||||||
Vocational Futures Planning | 39993.10 | ||||||||||||||||||||||
|
Estimate of Factor D.
ii. Concurrent §1915(b)/§1915(c) Waivers, or other authorities utilizing capitated arrangements (i.e., 1915(a), 1932(a), Section 1937).
Waiver Service/ Component | Capi-tation | Unit | # Users | Avg. Units Per User | Avg. Cost/ Unit | Component Cost | Total Cost | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Adult Day Care Total: | 835279.74 | ||||||||||||||||||||||
Adult Day Care | 835279.74 | ||||||||||||||||||||||
Daily Living Skills Training Total: | 223011.65 | ||||||||||||||||||||||
Daily Living Skills Training | 223011.65 | ||||||||||||||||||||||
IRIS Consultant Services Total: | 0.00 | ||||||||||||||||||||||
IRIS Consultant Services | 0.00 | ||||||||||||||||||||||
Live-in Caregiver (42 CFR §441.303(f)(8)) Total: | 262712.40 | ||||||||||||||||||||||
Live-in Caregiver (42 CFR §441.303(f)(8)) | 262712.40 | ||||||||||||||||||||||
Prevocational Services Total: | 72394.99 | ||||||||||||||||||||||
Prevocational Services | 72394.99 | ||||||||||||||||||||||
Respite Total: | 1522673.10 | ||||||||||||||||||||||
Respite | 1522673.10 | ||||||||||||||||||||||
Supported Employment Total: | 8828.06 | ||||||||||||||||||||||
Supported Employment | 8828.06 | ||||||||||||||||||||||
Nursing Services Total: | 1469402.82 | ||||||||||||||||||||||
Nursing Services | 1469402.82 | ||||||||||||||||||||||
Fiscal / Employer Agent Services Total: | 0.00 | ||||||||||||||||||||||
Fiscal / Employer Agent Services | 0.00 | ||||||||||||||||||||||
1-2 Bed Adult Family Home Total: | 89915.45 | ||||||||||||||||||||||
1-2 Bed Adult Family Home | 89915.45 | ||||||||||||||||||||||
3-4 Bed Adult Family Home Total: | 317562.90 | ||||||||||||||||||||||
3-4 Bed Adult Family Home | 317562.90 | ||||||||||||||||||||||
Adaptive Aids Total: | 3455867.18 | ||||||||||||||||||||||
Adaptive Aids | 3455867.18 | ||||||||||||||||||||||
CBRF Total: | 972611.21 | ||||||||||||||||||||||
CBRF | 972611.21 | ||||||||||||||||||||||
Communication Aids Vendors/Interpreter Services Total: | 367022.45 | ||||||||||||||||||||||
Communication Aids Vendors/Interpreter Services | 367022.45 | ||||||||||||||||||||||
Consumer Education and Training Total: | 28361.30 | ||||||||||||||||||||||
Consumer Education and Training | 28361.30 | ||||||||||||||||||||||
Counseling and Therapeutic Services Total: | 1081857.35 | ||||||||||||||||||||||
Counseling and Therapeutic Services | 1081857.35 | ||||||||||||||||||||||
Customized Goods and Services Total: | 7017835.12 | ||||||||||||||||||||||
Customized Goods and Services | 7017835.12 | ||||||||||||||||||||||
Day Services Total: | 786059.97 | ||||||||||||||||||||||
Day Services | 786059.97 | ||||||||||||||||||||||
Home Delivered Meals Total: | 467155.84 | ||||||||||||||||||||||
Home Delivered Meals | 467155.84 | ||||||||||||||||||||||
Home Modification Total: | 1777038.21 | ||||||||||||||||||||||
Home Modification | 1777038.21 | ||||||||||||||||||||||
Housing Counseling Total: | 277347.25 | ||||||||||||||||||||||
Housing Counseling | 277347.25 | ||||||||||||||||||||||
Personal Emergency Response System Total: | 333166.59 | ||||||||||||||||||||||
Personal Emergency Response System | 333166.59 | ||||||||||||||||||||||
Relocation - Housing Start Up and Related Utility Costs Total: | 136528.50 | ||||||||||||||||||||||
Relocation - Housing Start Up and Related Utility Costs | 136528.50 | ||||||||||||||||||||||
Residential Care Apartment Complex Total: | 795825.19 | ||||||||||||||||||||||
Residential Care Apartment Complex | 795825.19 | ||||||||||||||||||||||
Specialized Medical Equipment and Supplies Total: | 217348.04 | ||||||||||||||||||||||
Specialized Medical Equipment and Supplies | 217348.04 | ||||||||||||||||||||||
Specialized Transportation 2 Total: | 626130.09 | ||||||||||||||||||||||
Specialized Transportation 2 | 626130.09 | ||||||||||||||||||||||
Specialized Transportation Total: | 1999788.97 | ||||||||||||||||||||||
Specialized Transportation | 1999788.97 | ||||||||||||||||||||||
Support Broker Total: | 426254.79 | ||||||||||||||||||||||
Support Broker | 426254.79 | ||||||||||||||||||||||
Supportive Home Care Total: | 73863867.61 | ||||||||||||||||||||||
Supportive Home Care | 73863867.61 | ||||||||||||||||||||||
Vocational Futures Planning Total: | 40169.33 | ||||||||||||||||||||||
Vocational Futures Planning | 40169.33 | ||||||||||||||||||||||
|
Estimate of Factor D.
ii. Concurrent §1915(b)/§1915(c) Waivers, or other authorities utilizing capitated arrangements (i.e., 1915(a), 1932(a), Section 1937).
Waiver Service/ Component | Capi-tation | Unit | # Users | Avg. Units Per User | Avg. Cost/ Unit | Component Cost | Total Cost | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Adult Day Care Total: | 976077.40 | ||||||||||||||||||||||
Adult Day Care | 976077.40 | ||||||||||||||||||||||
Daily Living Skills Training Total: | 254129.40 | ||||||||||||||||||||||
Daily Living Skills Training | 254129.40 | ||||||||||||||||||||||
IRIS Consultant Services Total: | 18909404.80 | ||||||||||||||||||||||
IRIS Consultant Services | 18909404.80 | ||||||||||||||||||||||
Live-in Caregiver (42 CFR §441.303(f)(8)) Total: | 300263.60 | ||||||||||||||||||||||
Live-in Caregiver (42 CFR §441.303(f)(8)) | 300263.60 | ||||||||||||||||||||||
Prevocational Services Total: | 82210.68 | ||||||||||||||||||||||
Prevocational Services | 82210.68 | ||||||||||||||||||||||
Respite Total: | 1883149.78 | ||||||||||||||||||||||
Respite | 1883149.78 | ||||||||||||||||||||||
Supported Employment Total: | 10026.64 | ||||||||||||||||||||||
Supported Employment | 10026.64 | ||||||||||||||||||||||
Nursing Services Total: | 1726212.15 | ||||||||||||||||||||||
Nursing Services | 1726212.15 | ||||||||||||||||||||||
Fiscal / Employer Agent Services Total: | 5163722.08 | ||||||||||||||||||||||
Fiscal / Employer Agent Services | 5163722.08 | ||||||||||||||||||||||
1-2 Bed Adult Family Home Total: | 106240.95 | ||||||||||||||||||||||
1-2 Bed Adult Family Home | 106240.95 | ||||||||||||||||||||||
3-4 Bed Adult Family Home Total: | 360785.23 | ||||||||||||||||||||||
3-4 Bed Adult Family Home | 360785.23 | ||||||||||||||||||||||
Adaptive Aids Total: | 4066785.45 | ||||||||||||||||||||||
Adaptive Aids | 4066785.45 | ||||||||||||||||||||||
CBRF Total: | 0.00 | ||||||||||||||||||||||
CBRF | 0.00 | ||||||||||||||||||||||
Communication Aids Vendors/Interpreter Services Total: | 431447.34 | ||||||||||||||||||||||
Communication Aids Vendors/Interpreter Services | 431447.34 | ||||||||||||||||||||||
Consumer Education and Training Total: | 33586.56 | ||||||||||||||||||||||
Consumer Education and Training | 33586.56 | ||||||||||||||||||||||
Counseling and Therapeutic Services Total: | 1271109.46 | ||||||||||||||||||||||
Counseling and Therapeutic Services | 1271109.46 | ||||||||||||||||||||||
Customized Goods and Services Total: | 8229859.92 | ||||||||||||||||||||||
Customized Goods and Services | 8229859.92 | ||||||||||||||||||||||
Day Services Total: | 922199.44 | ||||||||||||||||||||||
Day Services | 922199.44 | ||||||||||||||||||||||
Home Delivered Meals Total: | 551710.08 | ||||||||||||||||||||||
Home Delivered Meals | 551710.08 | ||||||||||||||||||||||
Home Modification Total: | 2094944.67 | ||||||||||||||||||||||
Home Modification | 2094944.67 | ||||||||||||||||||||||
Housing Counseling Total: | 326713.55 | ||||||||||||||||||||||
Housing Counseling | 326713.55 | ||||||||||||||||||||||
Personal Emergency Response System Total: | 390779.63 | ||||||||||||||||||||||
Personal Emergency Response System | 390779.63 | ||||||||||||||||||||||
Relocation - Housing Start Up and Related Utility Costs Total: | 160746.01 | ||||||||||||||||||||||
Relocation - Housing Start Up and Related Utility Costs | 160746.01 | ||||||||||||||||||||||
Residential Care Apartment Complex Total: | 944006.72 | ||||||||||||||||||||||
Residential Care Apartment Complex | 944006.72 | ||||||||||||||||||||||
Specialized Medical Equipment and Supplies Total: | 254889.75 | ||||||||||||||||||||||
Specialized Medical Equipment and Supplies | 254889.75 | ||||||||||||||||||||||
Specialized Transportation 2 Total: | 738580.95 | ||||||||||||||||||||||
Specialized Transportation 2 | 738580.95 | ||||||||||||||||||||||
Specialized Transportation Total: | 2357710.74 | ||||||||||||||||||||||
Specialized Transportation | 2357710.74 | ||||||||||||||||||||||
Support Broker Total: | 502522.34 | ||||||||||||||||||||||
Support Broker | 502522.34 | ||||||||||||||||||||||
Supportive Home Care Total: | 87313654.59 | ||||||||||||||||||||||
Supportive Home Care | 87313654.59 | ||||||||||||||||||||||
Vocational Futures Planning Total: | 47948.24 | ||||||||||||||||||||||
Vocational Futures Planning | 47948.24 | ||||||||||||||||||||||
|