Application for a §1915(c) Home and Community-Based Services Waiver

PURPOSE OF THE HCBS WAIVER PROGRAM

The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in §1915(c) of the Social Security Act. The program permits a State to furnish an array of home and community-based services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. The State has broad discretion to design its waiver program to address the needs of the waiver’s target population. Waiver services complement and/or supplement the services that are available to participants through the Medicaid State plan and other federal, state and local public programs as well as the supports that families and communities provide.

The Centers for Medicare & Medicaid Services (CMS) recognizes that the design and operational features of a waiver program will vary depending on the specific needs of the target population, the resources available to the State, service delivery system structure, State goals and objectives, and other factors. A State has the latitude to design a waiver program that is cost-effective and employs a variety of service delivery approaches, including participant direction of services.

Request for an Amendment to a §1915(c) Home and Community-Based Services Waiver

1. Request Information

  1. The State of Wisconsin requests approval for an amendment to the following Medicaid home and community-based services waiver approved under authority of §1915(c) of the Social Security Act.
  2. Self Directed Supports- Elderly and PD
  3. WI.0485
  4. WI.0485.R01.07
  5. 01/08/15
    01/01/11

2. Purpose(s) of Amendment

Purpose(s) of the Amendment.
out of 12000

3. Nature of the Amendment

  1. Component(s) of the Approved Waiver Affected by the Amendment. This amendment affects the following component(s) of the approved waiver. Revisions to the affected subsection(s) of these component(s) are being submitted concurrently (check each that applies):
    Component of the Approved Waiver Subsection(s)
  2. Nature of the Amendment. Indicate the nature of the changes to the waiver that are proposed in the amendment (check each that applies):
    out of 6000
Application for a §1915(c) Home and Community-Based Services Waiver

1. Request Information (1 of 3)

  1. The State of Wisconsin requests approval for a Medicaid home and community-based services (HCBS) waiver under the authority of §1915(c) of the Social Security Act (the Act).
  2. (optional - this title will be used to locate this waiver in the finder):
  3. amendment
    (For new waivers requesting five year approval periods, the waiver must serve individuals who are dually eligible for Medicaid and Medicare.)
    WI.0485.R01.07
    WI.005.01.07
  4. 01/01/11
    01/01/11

1. Request Information (2 of 3)

  1. Level(s) of Care. This waiver is requested in order to provide home and community-based waiver services to individuals who, but for the provision of such services, would require the following level(s) of care, the costs of which would be reimbursed under the approved Medicaid State plan (check each that applies):
    Select applicable level of care
    out of 6000
    Select applicable level of care
    out of 6000
    out of 6000

1. Request Information (3 of 3)

  1. Concurrent Operation with Other Programs. This waiver operates concurrently with another program (or programs) approved under the following authorities
    Select one:
    Check the applicable authority or authorities:
    out of 6000
    Specify the §1915(b) authorities under which this program operates (check each that applies):
    out of 6000
    out of 6000
  2. Dual Eligiblity for Medicaid and Medicare.
    Check if applicable:

2. Brief Waiver Description

Brief Waiver Description.
out of 6000

3. Components of the Waiver Request

The waiver application consists of the following components. Note: Item 3-E must be completed.

  1. Waiver Administration and Operation. Appendix A specifies the administrative and operational structure of this waiver.

  2. 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.

  3. Participant Services. Appendix C specifies the home and community-based waiver services that are furnished through the waiver, including applicable limitations on such services.

  4. 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).

  5. Participant-Direction of Services. When the State provides for participant direction of services, Appendix E specifies the participant direction opportunities that are offered in the waiver and the supports that are available to participants who direct their services. (Select one):
    Appendix E is required.
    Appendix E is not required.
  6. 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.

  7. Participant Safeguards. Appendix G describes the safeguards that the State has established to assure the health and welfare of waiver participants in specified areas.

  8. Quality Improvement Strategy. Appendix H contains the Quality Improvement Strategy for this waiver.

  9. 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.

  10. Cost-Neutrality Demonstration. Appendix J contains the State's demonstration that the waiver is cost-neutral.

4. Waiver(s) Requested

  1. Comparability. The State requests a waiver of the requirements contained in §1902(a)(10)(B) of the Act in order to provide the services specified in Appendix C that are not otherwise available under the approved Medicaid State plan to individuals who: (a) require the level(s) of care specified in Item 1.F and (b) meet the target group criteria specified in Appendix B.
  2. Income and Resources for the Medically Needy. Indicate whether the State requests a waiver of §1902(a)(10)(C)(i)(III) of the Act in order to use institutional income and resource rules for the medically needy (select one):
  3. Statewideness. Indicate whether the State requests a waiver of the statewideness requirements in §1902(a)(1) of the Act (select one):
    If yes, specify the waiver of statewideness that is requested (check each that applies):
    out of 6000
    out of 6000

5. Assurances

In accordance with 42 CFR §441.302, the State provides the following assurances to CMS:
  1. 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:

    1. As specified in Appendix C, adequate standards for all types of providers that provide services under this waiver;

    2. 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,

    3. 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.

  2. 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.

  3. 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.

  4. 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:

    1. Informed of any feasible alternatives under the waiver; and,

    2. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. 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.

  10. Services for Individuals with Chronic Mental Illness. The State assures that federal financial participation (FFP) will not be claimed in expenditures for waiver services including, but not limited to, day treatment or partial hospitalization, psychosocial rehabilitation services, and clinic services provided as home and community-based services to individuals with chronic mental illnesses if these individuals, in the absence of a waiver, would be placed in an IMD and are: (1) age 22 to 64; (2) age 65 and older and the State has not included the optional Medicaid benefit cited in 42 CFR §440.140; or (3) age 21 and under and the State has not included the optional Medicaid benefit cited in 42 CFR § 440.160.

6. Additional Requirements

Note: Item 6-I must be completed.
  1. 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.

  2. 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.

  3. 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.

  4. Access to Services. The State does not limit or restrict participant access to waiver services except as provided in Appendix C.

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. Public Input.
    out of 6000
  10. 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.

  11. Limited English Proficient Persons. The State assures that it provides meaningful access to waiver services by Limited English Proficient persons in accordance with: (a) Presidential Executive Order 13166 of August 11, 2000 (65 FR 50121) and (b) Department of Health and Human Services "Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons" (68 FR 47311 - August 8, 2003). Appendix B describes how the State assures meaningful access to waiver services by Limited English Proficient persons.

7. Contact Person(s)

  1. The Medicaid agency representative with whom CMS should communicate regarding the waiver is:

    Wisconsin

  2. If applicable, the State operating agency representative with whom CMS should communicate regarding the waiver is:

    Wisconsin

8. Authorizing Signature

This document, together with the attached revisions to the affected components of the waiver, constitutes the State's request to amend its approved waiver under §1915(c) of the Social Security Act. The State affirms that it will abide by all provisions of the waiver, including the provisions of this amendment when approved by CMS. The State further attests that it will continuously operate the waiver in accordance with the assurances specified in Section V and the additional requirements specified in Section VI of the approved waiver. The State certifies that additional proposed revisions to the waiver request will be submitted by the Medicaid agency in the form of additional waiver amendments.

State Medicaid Director or Designee

Note: The Signature and Submission Date fields will be automatically completed when the State Medicaid Director submits the application.

Wisconsin

Attachments

Specify the transition plan for the waiver:

out of 12000

Specify the state's process to bring this waiver into compliance with federal home and community-based (HCB) settings requirements at 42 CFR 441.301(c)(4)-(5), and associated CMS guidance.
Consult with CMS for instructions before completing this item. This field describes the status of a transition process at the point in time of submission. Relevant information in the planning phase will differ from information required to describe attainment of milestones.
To the extent that the state has submitted a statewide HCB settings transition plan to CMS, the description in this field may reference that statewide plan. The narrative in this field must include enough information to demonstrate that this waiver complies with federal HCB settings requirements, including the compliance and transition requirements at 42 CFR 441.301(c)(6), and that this submission is consistent with the portions of the statewide HCB settings transition plan that are germane to this waiver. Quote or summarize germane portions of the statewide HCB settings transition plan as required.
Note that Appendix C-5 HCB Settings describes settings that do not require transition; the settings listed there meet federal HCB setting requirements as of the date of submission. Do not duplicate that information here.
Update this field and Appendix C-5 when submitting a renewal or amendment to this waiver for other purposes. It is not necessary for the state to amend the waiver solely for the purpose of updating this field and Appendix C-5. At the end of the state's HCB settings transition process for this waiver, when all waiver settings meet federal HCB setting requirements, enter "Completed" in this field, and include in Section C-5 the information on all HCB settings in the waiver.

out of 60000

Additional Needed Information (Optional)

out of 60000

Appendix A: Waiver Administration and Operation

  1. State Line of Authority for Waiver Operation. Specify the state line of authority for the operation of the waiver (select one):

    Specify the Medicaid agency division/unit that has line authority for the operation of the waiver program (select one):

    (Do not complete item A-2)

    (Complete item A-2-a).

    In accordance with 42 CFR §431.10, the Medicaid agency exercises administrative discretion in the administration and supervision of the waiver and issues policies, rules and regulations related to the waiver. The interagency agreement or memorandum of understanding that sets forth the authority and arrangements for this policy is available through the Medicaid agency to CMS upon request. (Complete item A-2-b).

Appendix A: Waiver Administration and Operation

  1. Oversight of Performance.

    1. Medicaid Director Oversight of Performance When the Waiver is Operated by another Division/Unit within the State Medicaid Agency.
      out of 12000
    2. Medicaid Agency Oversight of Operating Agency Performance.
      As indicated in section 1 of this appendix, the waiver is not operated by a separate agency of the State. Thus this section does not need to be completed.
      out of 12000

Appendix A: Waiver Administration and Operation

  1. Use of Contracted Entities. Specify whether contracted entities perform waiver operational and administrative functions on behalf of the Medicaid agency and/or the operating agency (if applicable) (select one):
    out of 6000

Appendix A: Waiver Administration and Operation

  1. Role of Local/Regional Non-State Entities. Indicate whether local or regional non-state entities perform waiver operational and administrative functions and, if so, specify the type of entity (Select One):

    - Local/regional non-state agencies perform waiver operational and administrative functions.
    Check each that applies:

    out of 6000

    out of 6000

Appendix A: Waiver Administration and Operation

  1. Responsibility for Assessment of Performance of Contracted and/or Local/Regional Non-State Entities.
    out of 6000

Appendix A: Waiver Administration and Operation

  1. Assessment Methods and Frequency.
    out of 12000

Appendix A: Waiver Administration and Operation

  1. Distribution of Waiver Operational and Administrative Functions. In the following table, specify the entity or entities that have responsibility for conducting each of the waiver operational and administrative functions listed (check each that applies):
    In accordance with 42 CFR §431.10, when the Medicaid agency does not directly conduct a function, it supervises the performance of the function and establishes and/or approves policies that affect the function. All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. Note: More than one box may be checked per item. Ensure that Medicaid is checked when the Single State Medicaid Agency (1) conducts the function directly; (2) supervises the delegated function; and/or (3) establishes and/or approves policies related to the function.
    FunctionMedicaid AgencyContracted Entity
    Participant waiver enrollment
    Waiver enrollment managed against approved limits
    Waiver expenditures managed against approved levels
    Level of care evaluation
    Review of Participant service plans
    Prior authorization of waiver services
    Utilization management
    Qualified provider enrollment
    Execution of Medicaid provider agreements
    Establishment of a statewide rate methodology
    Rules, policies, procedures and information development governing the waiver program
    Quality assurance and quality improvement activities

Appendix A: Waiver Administration and Operation

Quality Improvement: Administrative Authority of the Single State Medicaid Agency

As a distinct component of the State’s quality improvement strategy, provide information in the following fields to detail the State’s methods for discovery and remediation.
  1. Methods for Discovery: Administrative Authority
    The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.
    1. Performance Measures

      For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Performance measures for administrative authority should not duplicate measures found in other appendices of the waiver application. As necessary and applicable, performance measures should focus on:
      • Uniformity of development/execution of provider agreements throughout all geographic areas covered by the waiver
      • Equitable distribution of waiver openings in all geographic areas covered by the waiver
      • Compliance with HCB settings requirements and other new regulatory components (for waiver actions submitted on or after March 17, 2014)

      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.
      Other
      Reports to SMA from IRIS Consultant Agencies per certification criteria.
      Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
      Data Aggregation and Analysis:
      Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      Performance Measure:
      Number and 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.
      Other
      Reports provided from the F/EAs per Certification Criteria.
      Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
      Data Aggregation and Analysis:
      Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      Performance Measure:
      Number and 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.
      Other
      Long-Term Care Functional Screen data and Enrollment data
      Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
      Data Aggregation and Analysis:
      Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      Performance Measure:
      Number and 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.
      Other
      Long-Term Care Functional Screen and Enrollment data
      Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
      Data Aggregation and Analysis:
      Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      Performance Measure:
      Number and 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.
      Other
      IRIS Centralized IT System - The source data is currently originating from the centralized IT system which holds the participants’ current and historic plans.
      Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
      Data Aggregation and Analysis:
      Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      Performance Measure:
      Number and 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.
      Record reviews, on-site
      Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
      Data Aggregation and Analysis:
      Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      Performance Measure:
      Number and 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.
      Other
      ICAs' screener reports submitted to SMA
      Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
      Data Aggregation and Analysis:
      Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      Performance Measure:
      Number and 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.
      Other
      Inter-rater reliability test results
      Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
      Data Aggregation and Analysis:
      Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      Performance Measure:
      Number and 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.
      Record reviews, on-site
      Service plan and claims data will be taken from the centralized IT system.
      Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
      Data Aggregation and Analysis:
      Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      Performance Measure:
      Number and 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.
      Other
      F/EAs reports
      Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
      Data Aggregation and Analysis:
      Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      Performance Measure:
      Number and 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.
      Other
      TPA Reports
      Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
      Data Aggregation and Analysis:
      Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      Performance Measure:
      Number and 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.
      Other
      TPA Reports
      Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
      Data Aggregation and Analysis:
      Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
    2. out of 6000
  2. Methods for Remediation/Fixing Individual Problems
    1. out of 6000
    2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)
      Responsible Party(check each that applies): Frequency of data aggregation and analysis(check each that applies):
  3. Timelines
    out of 6000

Appendix B: Participant Access and Eligibility

B-1: Specification of the Waiver Target Group(s)

  1. Target Group(s). Under the waiver of Section 1902(a)(10)(B) of the Act, the State limits waiver services to one or more groups or subgroups of individuals. Please see the instruction manual for specifics regarding age limits. In accordance with 42 CFR §441.301(b)(6), select one or more waiver target groups, check each of the subgroups in the selected target group(s) that may receive services under the waiver, and specify the minimum and maximum (if any) age of individuals served in each subgroup:
    Target Group Included Target SubGroup Minimum Age Maximum Age
    Maximum Age Limit No Maximum Age Limit
    Aged
    Disabled (Physical)   
    Disabled (Other)   
    Brain Injury
    HIV/AIDS
    Medically Fragile
    Technology Dependent
    Autism
    Developmental Disability
    Intellectual Disability
    Mental Illness   
    Serious Emotional Disturbance   
  2. out of 12000
  3. out of 12000

Appendix B: Participant Access and Eligibility

B-2: Individual Cost Limit (1 of 2)

  1. Individual Cost Limit. The following individual cost limit applies when determining whether to deny home and community-based services or entrance to the waiver to an otherwise eligible individual (select one). Please note that a State may have only ONE individual cost limit for the purposes of determining eligibility for the waiver:
    The State does not apply an individual cost limit. Do not complete Item B-2-b or item B-2-c.
    The State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed the cost of a level of care specified for the waiver up to an amount specified by the State. Complete Items B-2-b and B-2-c.

    The limit specified by the State is (select one)

    out of 6000
    Pursuant to 42 CFR 441.301(a)(3), the State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed 100% of the cost of the level of care specified for the waiver. Complete Items B-2-b and B-2-c.
    The State refuses entrance to the waiver to any otherwise qualified individual when the State reasonably expects that the cost of home and community-based services furnished to that individual would exceed the following amount specified by the State that is less than the cost of a level of care specified for the waiver.

    out of 6000

    The cost limit specified by the State is (select one):

    The dollar amount (select one)

    out of 6000

    out of 6000

Appendix B: Participant Access and Eligibility

B-2: Individual Cost Limit (2 of 2)

Answers provided in Appendix B-2-a indicate that you do not need to complete this section.

  1. Method of Implementation of the Individual Cost Limit.

    out of 12000
  2. Participant Safeguards. When the State specifies an individual cost limit in Item B-2-a and there is a change in the participant's condition or circumstances post-entrance to the waiver that requires the provision of services in an amount that exceeds the cost limit in order to assure the participant's health and welfare, the State has established the following safeguards to avoid an adverse impact on the participant (check each that applies):

    out of 12000

    out of 12000

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (1 of 4)

  1. Unduplicated Number of Participants. The following table specifies the maximum number of unduplicated participants who are served in each year that the waiver is in effect. The State will submit a waiver amendment to CMS to modify the number of participants specified for any year(s), including when a modification is necessary due to legislative appropriation or another reason. The number of unduplicated participants specified in this table is basis for the cost-neutrality calculations in Appendix J:
    Table: B-3-a
    Waiver Year Unduplicated Number of Participants
    Year 1

    Year 2

    Year 3

    Year 4

    Year 5

  2. Limitation on the Number of Participants Served at Any Point in Time. Consistent with the unduplicated number of participants specified in Item B-3-a, the State may limit to a lesser number the number of participants who will be served at any point in time during a waiver year. Indicate whether the State limits the number of participants in this way: (select one):

    Table: B-3-b
    Waiver Year Maximum Number of Participants Served At Any Point During the Year
    Year 1

    Year 2

    Year 3

    Year 4

    Year 5

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (2 of 4)

  1. Reserved Waiver Capacity. The State may reserve a portion of the participant capacity of the waiver for specified purposes (e.g., provide for the community transition of institutionalized persons or furnish waiver services to individuals experiencing a crisis) subject to CMS review and approval. The State (select one):

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (3 of 4)

  1. Scheduled Phase-In or Phase-Out. Within a waiver year, the State may make the number of participants who are served subject to a phase-in or phase-out schedule (select one):
  2. Allocation of Waiver Capacity.

    Select one:

    out of 12000
  3. Selection of Entrants to the Waiver.

    out of 12000

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served - Attachment #1 (4 of 4)

Answers provided in Appendix B-3-d indicate that you do not need to complete this section.

Appendix B: Participant Access and Eligibility

B-4: Eligibility Groups Served in the Waiver

    1. State Classification. The State is a (select one):
    2. Miller Trust State.
      Indicate whether the State is a Miller Trust State (select one):
  1. Medicaid Eligibility Groups Served in the Waiver. Individuals who receive services under this waiver are eligible under the following eligibility groups contained in the State plan. The State applies all applicable federal financial participation limits under the plan. Check all that apply:
    Eligibility Groups Served in the Waiver (excluding the special home and community-based waiver group under 42 CFR §435.217)

    Select one:

    out of 6000
    Special home and community-based waiver group under 42 CFR §435.217) Note: When the special home and community-based waiver group under 42 CFR §435.217 is included, Appendix B-5 must be completed
    The State does not furnish waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217. Appendix B-5 is not submitted.
    The State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217.

    Check each that applies:

    Select one:

    Select one:

    out of 6000

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (1 of 7)

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.

  1. 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:

    Note: For the five-year period beginning January 1, 2014, the following instructions are mandatory. The following box should be checked for all waivers that furnish waiver services to the 42 CFR §435.217 group effective at any point during this time period.
    Complete Items B-5-e (if the selection for B-4-a-i is SSI State or §1634) or B-5-f (if the selection for B-4-a-i is 209b State) and Item B-5-g unless the state indicates that it also uses spousal post-eligibility rules for the time periods before January 1, 2014 or after December 31, 2018.
    Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018 (select one).

    In the case of a participant with a community spouse, the State elects to (select one):

    (Complete Item B-5-b (SSI State) and Item B-5-d)
    (Complete Item B-5-b (SSI State). Do not complete Item B-5-d)
    (Complete Item B-5-b (SSI State). Do not complete Item B-5-d)

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (2 of 7)

Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018.
  1. 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:

    1. Allowance for the needs of the waiver participant (select one):

      Select one:

      (select one):

      out of 36000

      If this amount changes, this item will be revised.

      out of 6000

      out of 6000
    2. Allowance for the spouse only (select one):

      out of 6000

      Specify the amount of the allowance (select one):

      If this amount changes, this item will be revised.

      out of 6000
    3. Allowance for the family (select one):

      The amount specified cannot exceed the higher of the need standard for a family of the same size used to determine eligibility under the State's approved AFDC plan or the medically needy income standard established under 42 CFR §435.811 for a family of the same size. If this amount changes, this item will be revised.

      out of 6000

      out of 6000
    4. Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 §CFR 435.726:

      1. Health insurance premiums, deductibles and co-insurance charges
      2. Necessary medical or remedial care expenses recognized under State law but not covered under the State's Medicaid plan, subject to reasonable limits that the State may establish on the amounts of these expenses.

      Select one:

      Note: If the State protects the maximum amount for the waiver participant, not applicable must be selected.

      out of 6000

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (3 of 7)

Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018.
  1. 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.

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (4 of 7)

Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018.
  1. 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).

    1. Allowance for the personal needs of the waiver participant

      (select one):

      If this amount changes, this item will be revised

      out of 4000

      out of 36000
    2. 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:

      out of 6000
    3. Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 CFR §435.726:

      1. Health insurance premiums, deductibles and co-insurance charges
      2. Necessary medical or remedial care expenses recognized under State law but not covered under the State's Medicaid plan, subject to reasonable limits that the State may establish on the amounts of these expenses.

      Select one:

      Note: If the State protects the maximum amount for the waiver participant, not applicable must be selected.

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (5 of 7)

Note: The following selections apply for the five-year period beginning January 1, 2014.
  1. 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.

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (6 of 7)

Note: The following selections apply for the five-year period beginning January 1, 2014.
  1. 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.

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (7 of 7)

Note: The following selections apply for the five-year period beginning January 1, 2014.
  1. 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).

    Answers provided in Appendix B-5-a indicate that you do not need to complete this section and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-6: Evaluation/Reevaluation of Level of Care

As specified in 42 CFR §441.302(c), the State provides for an evaluation (and periodic reevaluations) of the need for the level(s) of care specified for this waiver, when there is a reasonable indication that an individual may need such services in the near future (one month or less), but for the availability of home and community-based waiver services.
  1. 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:

    1. Minimum number of services.

    2. Frequency of services. The State requires (select one):

      out of 4000
  2. Responsibility for Performing Evaluations and Reevaluations. Level of care evaluations and reevaluations are performed (select one):

    out of 4000

    out of 4000
  3. Qualifications of Individuals Performing Initial Evaluation:

    out of 6000
  4. Level of Care Criteria.

    out of 12000
  5. Level of Care Instrument(s). Per 42 CFR §441.303(c)(2), indicate whether the instrument/tool used to evaluate level of care for the waiver differs from the instrument/tool used to evaluate institutional level of care (select one):

    out of 12000
  6. Process for Level of Care Evaluation/Reevaluation:

    out of 12000
  7. Reevaluation Schedule. Per 42 CFR §441.303(c)(4), reevaluations of the level of care required by a participant are conducted no less frequently than annually according to the following schedule (select one):

    out of 4000
  8. Qualifications of Individuals Who Perform Reevaluations. Specify the qualifications of individuals who perform reevaluations (select one):

    out of 6000
  9. Procedures to Ensure Timely Reevaluations.

    out of 6000
  10. Maintenance of Evaluation/Reevaluation Records.

    out of 6000

Appendix B: Evaluation/Reevaluation of Level of Care

Quality Improvement: Level of Care

As a distinct component of the State’s quality improvement strategy, provide information in the following fields to detail the State’s methods for discovery and remediation.
  1. Methods for Discovery: Level of Care Assurance/Sub-assurances

    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.

    1. Sub-Assurances:
      1. 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.
        Other
        Long-Term Care Functional Screen data and Enrollment data
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      2. 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.
        Other
        Long-Term Care Functional Screen data and Enrollment data
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      3. 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.

    2. out of 6000
  2. Methods for Remediation/Fixing Individual Problems
    1. out of 6000
    2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)
      Responsible Party(check each that applies): Frequency of data aggregation and analysis(check each that applies):
  3. Timelines
    out of 6000

Appendix B: Participant Access and Eligibility

B-7: Freedom of Choice

Freedom of Choice. As provided in 42 CFR §441.302(d), when an individual is determined to be likely to require a level of care for this waiver, the individual or his or her legal representative is:
  1. informed of any feasible alternatives under the waiver; and
  2. given the choice of either institutional or home and community-based services.
  1. Procedures.

    out of 12000
  2. Maintenance of Forms.

    out of 4000

Appendix B: Participant Access and Eligibility

B-8: Access to Services by Limited English Proficiency Persons

Access to Services by Limited English Proficient Persons.
out of 12000

Appendix C: Participant Services

C-1: Summary of Services Covered (1 of 2)

  1. Waiver Services Summary. List the services that are furnished under the waiver in the following table. If case management is not a service under the waiver, complete items C-1-b and C-1-c:
    Service TypeService
    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 Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Agency Adult Day Care provider

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service
Service Name: Adult Day Care
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Individual Daily living skills trainer
Agency Daily living skills training agency

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service
Service Name: Daily Living Skills Training
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service
Service Name: Daily Living Skills Training
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Agency IRIS Consultant Agency

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service
Service Name: IRIS Consultant Services
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Individual Individual Worker

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service
Service Name: Live-in Caregiver (42 CFR §441.303(f)(8))
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Agency Supported Employment Agency or Facility-Based Workshop

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service
Service Name: Prevocational Services
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Agency CBRF or RCAC
Agency Adult Family Home 3 to 4 Bed
Individual Adult Family Home - 1 to 2 Bed, Individual Respite Provider

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service
Service Name: Respite
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service
Service Name: Respite
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service
Service Name: Respite
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Individual On-the-job support person
Agency Supported Employment Agency

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service
Service Name: Supported Employment
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service
Service Name: Supported Employment
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Agency Agency-directed registered nurse/LPN
Individual Registered Nurse/LPN

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Extended State Plan Service
Service Name: Nursing Services
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Extended State Plan Service
Service Name: Nursing Services
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
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):

Provider CategoryProvider Type Title
Agency Fiscal / Employer Agent

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Supports for Participant Direction
Service Name: Fiscal / Employer Agent Services
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Individual Adult Family Home

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: 1-2 Bed Adult Family Home
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Agency Adult Family Home

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: 3-4 Bed Adult Family Home
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Agency Adaptive Aids Vendor

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Adaptive Aids
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Individual CBRF

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: CBRF
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Individual Individual Interpreters
Agency Communication Aids vendor

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Communication Aids Vendors/Interpreter Services
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Communication Aids Vendors/Interpreter Services
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Agency Education and training agency
Individual Personal assistant, teacher

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Consumer Education and Training
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Consumer Education and Training
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Individual Individual counselors
Agency Counseling agencies

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Counseling and Therapeutic Services
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Counseling and Therapeutic Services
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Individual Family, friend, neighbor, supportive home care worker
Agency Home Health Care Agency, Supportive Home Care Agency, Aging Network Agency, Education and Training Agency, Other Merchants or Contractors.

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Customized Goods and Services
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Customized Goods and Services
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Agency Day Service program operated by agency

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Day Services
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Agency Aging network agencies, hospitals or nursing homes, restaurants

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Home Delivered Meals
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Individual Carpenter, electrician, plumber, contractor, engineer

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Home Modification
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Agency Housing Counseling Agency

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Housing Counseling
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Agency PERS Vendor

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Personal Emergency Response System
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Agency Moving companies, public utilities, real estate agencies, vendors of home furnishings

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Relocation - Housing Start Up and Related Utility Costs
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Agency Residential Care Apartment Complex

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Residential Care Apartment Complex
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Individual Purchase of services - other merchants
Agency Authorized DME Vendor

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Specialized Medical Equipment and Supplies
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Specialized Medical Equipment and Supplies
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Individual Same as other Specialized Transportation

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Specialized Transportation 2
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Agency Mass transit provider, taxi or common carrier, specialized transportation provider
Individual Individual provider

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Specialized Transportation
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Specialized Transportation
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Individual Individual Support Broker
Agency Support Broker Agency

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Support Broker
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Support Broker
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Individual Individual worker
Agency Supportive Home Care agency, Home Health Care agency

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Supportive Home Care
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Supportive Home Care
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

HCBS Taxonomy:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider CategoryProvider Type Title
Agency Aging and Disability Resource Center, Employment agency, Supportive Employment agency

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service
Service Name: Vocational Futures Planning
Provider Qualifications
Verification of Provider Qualifications

Appendix C: Participant Services

C-1: Summary of Services Covered (2 of 2)

  1. Provision of Case Management Services to Waiver Participants. Indicate how case management is furnished to waiver participants (select one):
    - Case management is not furnished as a distinct activity to waiver participants.
    - Case management is furnished as a distinct activity to waiver participants.
    Check each that applies:
    Do not complete item C-1-c.
    Complete item C-1-c.
    Complete item C-1-c.
    Complete item C-1-c. NOTE: Pursuant to CMS-2237-IFC this selection is no longer available for 1915(c) waivers.
    Do not complete item C-1-c.
    - Case management is furnished as a waiver service (Do not complete item C-1-c).
  2. Delivery of Case Management Services.

    out of 4000

Appendix C: Participant Services

C-2: General Service Specifications (1 of 3)

  1. Criminal History and/or Background Investigations.

    out of 12000
  2. Abuse Registry Screening.

    out of 12000

Appendix C: Participant Services

C-2: General Service Specifications (2 of 3)

  1. Services in Facilities Subject to §1616(e) of the Social Security Act. Select one:

    1. Facility Type
      1 to 4 Bed Adult Family Homes
      Community Based Residential Facility (CBRF)
      Residential Care Apartment Complex (RCAC)
    2. out of 12000

Appendix C: Participant Services

C-2: Facility Specifications

Waiver ServiceProvided in Facility
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

Scope of Facility Sandards. For this facility type, please specify whether the State's standards address the following topics (check each that applies):

Scope of State Facility Standards
Standard Topic Addressed
Admission policies
Physical environment
Sanitation
Safety
Staff : resident ratios
Staff training and qualifications
Staff supervision
Resident rights
Medication administration
Use of restrictive interventions
Incident reporting
Provision of or arrangement for necessary health services

Appendix C: Participant Services

C-2: Facility Specifications

Waiver ServiceProvided in Facility
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

Scope of Facility Sandards. For this facility type, please specify whether the State's standards address the following topics (check each that applies):

Scope of State Facility Standards
Standard Topic Addressed
Admission policies
Physical environment
Sanitation
Safety
Staff : resident ratios
Staff training and qualifications
Staff supervision
Resident rights
Medication administration
Use of restrictive interventions
Incident reporting
Provision of or arrangement for necessary health services

Appendix C: Participant Services

C-2: Facility Specifications

Waiver ServiceProvided in Facility
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

Scope of Facility Sandards. For this facility type, please specify whether the State's standards address the following topics (check each that applies):

Scope of State Facility Standards
Standard Topic Addressed
Admission policies
Physical environment
Sanitation
Safety
Staff : resident ratios
Staff training and qualifications
Staff supervision
Resident rights
Medication administration
Use of restrictive interventions
Incident reporting
Provision of or arrangement for necessary health services

Appendix C: Participant Services

C-2: General Service Specifications (3 of 3)

  1. Provision of Personal Care or Similar Services by Legally Responsible Individuals. A legally responsible individual is any person who has a duty under State law to care for another person and typically includes: (a) the parent (biological or adoptive) of a minor child or the guardian of a minor child who must provide care to the child or (b) a spouse of a waiver participant. Except at the option of the State and under extraordinary circumstances specified by the State, payment may not be made to a legally responsible individual for the provision of personal care or similar services that the legally responsible individual would ordinarily perform or be responsible to perform on behalf of a waiver participant. Select one:

    out of 12000
  2. Other State Policies Concerning Payment for Waiver Services Furnished by Relatives/Legal Guardians. Specify State policies concerning making payment to relatives/legal guardians for the provision of waiver services over and above the policies addressed in Item C-2-d. Select one:

    out of 12000

    out of 12000

    out of 12000
  3. Open Enrollment of Providers.

    out of 12000

Appendix C: Participant Services

Quality Improvement: Qualified Providers

As a distinct component of the State’s quality improvement strategy, provide information in the following fields to detail the State’s methods for discovery and remediation.
  1. Methods for Discovery: Qualified Providers

    The state demonstrates that it has designed and implemented an adequate system for assuring that all waiver services are provided by qualified providers.

    1. Sub-Assurances:
      1. 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.
        Other
        TPA reports
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
        Performance Measure:
        Number and 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.
        Other
        TPA reports
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
        Performance Measure:
        Number and 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.
        Other
        F/EAs reports
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      2. 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.
        Other
        F/EA reports
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      3. 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.

    2. out of 6000
  2. Methods for Remediation/Fixing Individual Problems
    1. out of 6000
    2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)
      Responsible Party(check each that applies): Frequency of data aggregation and analysis(check each that applies):
  3. Timelines
    out of 6000

Appendix C: Participant Services

C-3: Waiver Services Specifications

Section C-3 'Service Specifications' is incorporated into Section C-1 'Waiver Services.'

Appendix C: Participant Services

C-4: Additional Limits on Amount of Waiver Services

  1. Additional Limits on Amount of Waiver Services. Indicate whether the waiver employs any of the following additional limits on the amount of waiver services (select one).

    - The State does not impose a limit on the amount of waiver services except as provided in Appendix C-3.
    - The State imposes additional limits on the amount of waiver services.

    When a limit is employed, specify: (a) the waiver services to which the limit applies; (b) the basis of the limit, including its basis in historical expenditure/utilization patterns and, as applicable, the processes and methodologies that are used to determine the amount of the limit to which a participant's services are subject; (c) how the limit will be adjusted over the course of the waiver period; (d) provisions for adjusting or making exceptions to the limit based on participant health and welfare needs or other factors specified by the state; (e) the safeguards that are in effect when the amount of the limit is insufficient to meet a participant's needs; (f) how participants are notified of the amount of the limit. (check each that applies)

    out of 24000

    out of 24000

    out of 24000

    out of 24000

Appendix C: Participant Services

C-5: Home and Community-Based Settings

  1. Description of the settings and how they meet federal HCB Settings requirements, at the time of submission and in the future.

  2. 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.

Note instructions at Module 1, Attachment #2, HCB Settings Waiver Transition Plan for description of settings that do not meet requirements at the time of submission. Do not duplicate that information here.

out of 60000

Appendix D: Participant-Centered Planning and Service Delivery

D-1: Service Plan Development (1 of 8)

  1. Responsibility for Service Plan Development. Per 42 CFR §441.301(b)(2), specify who is responsible for the development of the service plan and the qualifications of these individuals (select each that applies):

    out of 6000

    out of 6000

    out of 6000

Appendix D: Participant-Centered Planning and Service Delivery

D-1: Service Plan Development (2 of 8)

  1. Service Plan Development Safeguards. Select one:

    out of 6000

Appendix D: Participant-Centered Planning and Service Delivery

D-1: Service Plan Development (3 of 8)

  1. Supporting the Participant in Service Plan Development.

    out of 12000

Appendix D: Participant-Centered Planning and Service Delivery

D-1: Service Plan Development (4 of 8)

  1. Service Plan Development Process.

    out of 24000

Appendix D: Participant-Centered Planning and Service Delivery

D-1: Service Plan Development (5 of 8)

  1. Risk Assessment and Mitigation.

    out of 12000

Appendix D: Participant-Centered Planning and Service Delivery

D-1: Service Plan Development (6 of 8)

  1. Informed Choice of Providers.

    out of 6000

Appendix D: Participant-Centered Planning and Service Delivery

D-1: Service Plan Development (7 of 8)

  1. Process for Making Service Plan Subject to the Approval of the Medicaid Agency.

    out of 6000

Appendix D: Participant-Centered Planning and Service Delivery

D-1: Service Plan Development (8 of 8)

  1. Service Plan Review and Update. The service plan is subject to at least annual periodic review and update to assess the appropriateness and adequacy of the services as participant needs change.

    out of 6000
  2. Maintenance of Service Plan Forms. Written copies or electronic facsimiles of service plans are maintained for a minimum period of 3 years as required by 45 CFR §92.42. Service plans are maintained by the following (check each that applies):

    out of 4000

Appendix D: Participant-Centered Planning and Service Delivery

D-2: Service Plan Implementation and Monitoring

  1. Service Plan Implementation and Monitoring.

    out of 24000
  2. Monitoring Safeguards. Select one:

    out of 24000

Appendix D: Participant-Centered Planning and Service Delivery

Quality Improvement: Service Plan

As a distinct component of the State’s quality improvement strategy, provide information in the following fields to detail the State’s methods for discovery and remediation.
  1. Methods for Discovery: Service Plan Assurance/Sub-assurances

    The state demonstrates it has designed and implemented an effective system for reviewing the adequacy of service plans for waiver participants.

    1. Sub-Assurances:
      1. 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.
        Record reviews, on-site
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
        Performance Measure:
        Number and 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.
        Record reviews, on-site
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
        Performance Measure:
        Number and 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.
        Record reviews, on-site
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      2. 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.
        Record reviews, on-site
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
        Performance Measure:
        Number and 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.
        Other
        Service plan data
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
        Performance Measure:
        Number and 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.
        Record reviews, on-site
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      3. Sub-assurance: Service plans are updated/revised at least annually or when warranted by changes in the waiver participant’s needs.

        Performance Measures

        For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

        For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

        Performance Measure:
        Number and percent of 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.
        Record reviews, on-site
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
        Performance Measure:
        Number and 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.
        Record reviews, on-site
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      4. 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.
        Record reviews, on-site
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      5. 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.
        Record reviews, on-site
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
        Performance Measure:
        Number and 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.
        Record reviews, on-site
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
    2. out of 6000
  2. Methods for Remediation/Fixing Individual Problems
    1. out of 6000
    2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)
      Responsible Party(check each that applies): Frequency of data aggregation and analysis(check each that applies):

  3. Timelines
    out of 6000

Appendix E: Participant Direction of Services

Applicability (from Application Section 3, Components of the Waiver Request):

Complete the remainder of the Appendix.
Do not complete the remainder of the Appendix.

CMS urges states to afford all waiver participants the opportunity to direct their services. Participant direction of services includes the participant exercising decision-making authority over workers who provide services, a participant-managed budget or both. CMS will confer the Independence Plus designation when the waiver evidences a strong commitment to participant direction.

Indicate whether Independence Plus designation is requested (select one):

Appendix E: Participant Direction of Services

E-1: Overview (1 of 13)

  1. Description of Participant Direction.

    out of 12000

Appendix E: Participant Direction of Services

E-1: Overview (2 of 13)

  1. Participant Direction Opportunities. Specify the participant direction opportunities that are available in the waiver. Select one:

    As specified in Appendix E-2, Item a, the participant (or the participant's representative) has decision-making authority over workers who provide waiver services. The participant may function as the common law employer or the co-employer of workers. Supports and protections are available for participants who exercise this authority.
    As specified in Appendix E-2, Item b, the participant (or the participant's representative) has decision-making authority over a budget for waiver services. Supports and protections are available for participants who have authority over a budget.
    The waiver provides for both participant direction opportunities as specified in Appendix E-2. Supports and protections are available for participants who exercise these authorities.
  2. Availability of Participant Direction by Type of Living Arrangement. Check each that applies:

    out of 4000

Appendix E: Participant Direction of Services

E-1: Overview (3 of 13)

  1. Election of Participant Direction.

    out of 18000

Appendix E: Participant Direction of Services

E-1: Overview (4 of 13)

  1. Information Furnished to Participant.

    out of 12000

Appendix E: Participant Direction of Services

E-1: Overview (5 of 13)

  1. Participant Direction by a Representative.

    Specify the representatives who may direct waiver services: (check each that applies):

    out of 12000

Appendix E: Participant Direction of Services

E-1: Overview (6 of 13)

  1. Participant-Directed Services.

    Waiver ServiceEmployer AuthorityBudget Authority
    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

Appendix E: Participant Direction of Services

E-1: Overview (7 of 13)

  1. 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:

    (Complete item E-1-i).

    Specify whether governmental and/or private entities furnish these services. Check each that applies:

    Do not complete Item E-1-i.

Appendix E: Participant Direction of Services

E-1: Overview (8 of 13)

  1. 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

    1. Types of Entities:

      out of 12000
    2. Payment for FMS.

      out of 12000
    3. 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:

      out of 12000

      Supports furnished when the participant exercises budget authority:

      out of 12000

      Additional functions/activities:

      out of 12000
    4. Oversight of FMS Entities.

      out of 12000

Appendix E: Participant Direction of Services

E-1: Overview (9 of 13)

  1. 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):

    out of 6000
    Participant-Directed Waiver ServiceInformation and Assistance Provided through this Waiver Service Coverage
    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

    out of 12000

Appendix E: Participant Direction of Services

E-1: Overview (10 of 13)

  1. Independent Advocacy (select one).

    out of 12000

Appendix E: Participant Direction of Services

E-1: Overview (11 of 13)

  1. Voluntary Termination of Participant Direction.

    out of 12000

Appendix E: Participant Direction of Services

E-1: Overview (12 of 13)

  1. Involuntary Termination of Participant Direction.

    out of 12000

Appendix E: Participant Direction of Services

E-1: Overview (13 of 13)

  1. 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.

    Table E-1-n
    Employer Authority Only Budget Authority Only or Budget Authority in Combination with Employer Authority
    Waiver Year Number of Participants Number of Participants
    Year 1
    Year 2
    Year 3
    Year 4
    Year 5

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant Direction (1 of 6)

  1. Participant - Employer Authority Complete when the waiver offers the employer authority opportunity as indicated in Item E-1-b:

    1. Participant Employer Status. Specify the participant's employer status under the waiver. Select one or both:

      out of 6000
    2. 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:

      out of 4000

      out of 4000

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (2 of 6)

  1. Participant - Budget Authority Complete when the waiver offers the budget authority opportunity as indicated in Item E-1-b:

    1. 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:

      out of 4000

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (3 of 6)

  1. Participant - Budget Authority

    1. Participant-Directed Budget

      out of 12000

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (4 of 6)

  1. Participant - Budget Authority

    1. Informing Participant of Budget Amount.

      out of 12000

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (5 of 6)

  1. Participant - Budget Authority

    1. Participant Exercise of Budget Flexibility. Select one:

      out of 12000

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (6 of 6)

  1. Participant - Budget Authority

    1. Expenditure Safeguards.

      out of 12000

Appendix F: Participant Rights

Appendix F-1: Opportunity to Request a Fair Hearing

The State provides an opportunity to request a Fair Hearing under 42 CFR Part 431, Subpart E to individuals: (a) who are not given the choice of home and community-based services as an alternative to the institutional care specified in Item 1-F of the request; (b) are denied the service(s) of their choice or the provider(s) of their choice; or, (c) whose services are denied, suspended, reduced or terminated. The State provides notice of action as required in 42 CFR §431.210.

Procedures for Offering Opportunity to Request a Fair Hearing.

out of 12000

Appendix F: Participant-Rights

Appendix F-2: Additional Dispute Resolution Process

  1. 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:

  2. Description of Additional Dispute Resolution Process.

    out of 12000

Appendix F: Participant-Rights

Appendix F-3: State Grievance/Complaint System

  1. Operation of Grievance/Complaint System. Select one:

  2. Operational Responsibility.

    out of 4000
  3. Description of System.

    out of 12000

Appendix G: Participant Safeguards

Appendix G-1: Response to Critical Events or Incidents

  1. Critical Event or Incident Reporting and Management Process.

    (complete Items b through e)
    (do not complete Items b through e)

    out of 12000
  2. State Critical Event or Incident Reporting Requirements.

    out of 24000
  3. Participant Training and Education.

    out of 12000
  4. Responsibility for Review of and Response to Critical Events or Incidents.

    out of 12000
  5. Responsibility for Oversight of Critical Incidents and Events.

    out of 12000

Appendix G: Participant Safeguards

Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (1 of 3)

  1. 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.)

    out of 12000
    . Complete Items G-2-a-i and G-2-a-ii.
    1. Safeguards Concerning the Use of Restraints.

      out of 12000
    2. State Oversight Responsibility.

      out of 12000

Appendix G: Participant Safeguards

Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (2 of 3)

  1. Use of Restrictive Interventions. (Select one):

    out of 12000
    Complete Items G-2-b-i and G-2-b-ii.
    1. Safeguards Concerning the Use of Restrictive Interventions.

      out of 20000
    2. State Oversight Responsibility.

      out of 20000

Appendix G: Participant Safeguards

Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (3 of 3)

  1. 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.)

    out of 12000
    . Complete Items G-2-c-i and G-2-c-ii.
    1. Safeguards Concerning the Use of Seclusion.

      out of 12000
    2. State Oversight Responsibility.

      out of 12000

Appendix G: Participant Safeguards

Appendix G-3: Medication Management and Administration (1 of 2)

This Appendix must be completed when waiver services are furnished to participants who are served in licensed or unlicensed living arrangements where a provider has round-the-clock responsibility for the health and welfare of residents. The Appendix does not need to be completed when waiver participants are served exclusively in their own personal residences or in the home of a family member.

  1. Applicability. Select one:

    (do not complete the remaining items)
    (complete the remaining items)
  2. Medication Management and Follow-Up

    1. Responsibility.

      out of 12000
    2. Methods of State Oversight and Follow-Up.

      out of 12000

Appendix G: Participant Safeguards

Appendix G-3: Medication Management and Administration (2 of 2)

  1. Medication Administration by Waiver Providers

    1. Provider Administration of Medications. Select one:

      (do not complete the remaining items)
      (complete the remaining items)
    2. State Policy.

      out of 12000
    3. Medication Error Reporting. Select one of the following:

      Complete the following three items:

      out of 12000

      out of 12000

      out of 12000

      out of 12000
    4. State Oversight Responsibility.

      out of 12000

Appendix G: Participant Safeguards

Quality Improvement: Health and Welfare

As a distinct component of the State’s quality improvement strategy, provide information in the following fields to detail the State’s methods for discovery and remediation.
  1. Methods for Discovery: Health and Welfare
    The state demonstrates it has designed and implemented an effective system for assuring waiver participant health and welfare. (For waiver actions submitted before June 1, 2014, this assurance read "The State, on an ongoing basis, identifies, addresses, and seeks to prevent the occurrence of abuse, neglect and exploitation.")
    1. Sub-Assurances:
      1. 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.
        Record reviews, on-site
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
        Performance Measure:
        Number and 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.
        Critical events and incident reports
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
        Performance Measure:
        Number and 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.
        Other
        Mortality review committee reports and critical incident reports
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
        Performance Measure:
        Number and 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.
        Other
        Restricitve measures data
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
        Performance Measure:
        Number and 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.
        Record reviews, on-site
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
        Performance Measure:
        Number and 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.
        Record reviews, on-site
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      2. 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.

      3. 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.

      4. 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.

    2. out of 6000
  2. Methods for Remediation/Fixing Individual Problems
    1. out of 6000
    2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)
      Responsible Party(check each that applies): Frequency of data aggregation and analysis(check each that applies):

  3. Timelines
    out of 6000

Appendix H: Quality Improvement Strategy (1 of 2)

Under §1915(c) of the Social Security Act and 42 CFR §441.302, the approval of an HCBS waiver requires that CMS determine that the State has made satisfactory assurances concerning the protection of participant health and welfare, financial accountability and other elements of waiver operations. Renewal of an existing waiver is contingent upon review by CMS and a finding by CMS that the assurances have been met. By completing the HCBS waiver application, the State specifies how it has designed the waiver’s critical processes, structures and operational features in order to meet these assurances.

CMS recognizes that a state’s waiver Quality Improvement Strategy may vary depending on the nature of the waiver target population, the services offered, and the waiver’s relationship to other public programs, and will extend beyond regulatory requirements. However, for the purpose of this application, the State is expected to have, at the minimum, systems in place to measure and improve its own performance in meeting six specific waiver assurances and requirements.

It may be more efficient and effective for a Quality Improvement Strategy to span multiple waivers and other long-term care services. CMS recognizes the value of this approach and will ask the state to identify other waiver programs and long-term care services that are addressed in the Quality Improvement Strategy.

Quality Improvement Strategy: Minimum Components

The Quality Improvement Strategy that will be in effect during the period of the approved waiver is described throughout the waiver in the appendices corresponding to the statutory assurances and sub-assurances. Other documents cited must be available to CMS upon request through the Medicaid agency or the operating agency (if appropriate).

In the 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.

Appendix H: Quality Improvement Strategy (2 of 2)

H-1: Systems Improvement

  1. System Improvements

    1. out of 12000
    2. System Improvement Activities
      Responsible Party(check each that applies): Frequency of Monitoring and Analysis(check each that applies):
  2. System Design Changes

    1. out of 12000
    2. out of 12000

Appendix I: Financial Accountability

I-1: Financial Integrity and Accountability

Financial Integrity.

out of 12000

Appendix I: Financial Accountability

Quality Improvement: Financial Accountability

As a distinct component of the State’s quality improvement strategy, provide information in the following fields to detail the State’s methods for discovery and remediation.
  1. Methods for Discovery: Financial Accountability
    State financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver. (For waiver actions submitted before June 1, 2014, this assurance read "State financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver.")
    1. Sub-Assurances:
      1. 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.
        Financial records (including expenditures)
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
        Performance Measure:
        Number and 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.
        Other
        Data integrity audit
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
        Performance Measure:
        Number and 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.
        Financial records (including expenditures)
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
        Performance Measure:
        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.
        Other
        Encounter reporting program database
        Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies):
        Data Aggregation and Analysis:
        Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies):
      2. 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.

    2. out of 6000
  2. Methods for Remediation/Fixing Individual Problems
    1. out of 6000
    2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)
      Responsible Party(check each that applies): Frequency of data aggregation and analysis(check each that applies):
  3. Timelines
    out of 6000

Appendix I: Financial Accountability

I-2: Rates, Billing and Claims (1 of 3)

  1. Rate Determination Methods.

    out of 12000
  2. Flow of Billings.

    out of 6000

Appendix I: Financial Accountability

I-2: Rates, Billing and Claims (2 of 3)

  1. Certifying Public Expenditures (select one):

    Select at least one:

    out of 6000

    out of 6000

Appendix I: Financial Accountability

I-2: Rates, Billing and Claims (3 of 3)

  1. Billing Validation Process.

    out of 6000
  2. Billing and Claims Record Maintenance Requirement. Records documenting the audit trail of adjudicated claims (including supporting documentation) are maintained by the Medicaid agency, the operating agency (if applicable), and providers of waiver services for a minimum period of 3 years as required in 45 CFR §92.42.

Appendix I: Financial Accountability

I-3: Payment (1 of 7)

  1. Method of payments -- MMIS (select one):

    out of 6000

    out of 6000

    out of 6000

Appendix I: Financial Accountability

I-3: Payment (2 of 7)

  1. Direct payment. In addition to providing that the Medicaid agency makes payments directly to providers of waiver services, payments for waiver services are made utilizing one or more of the following arrangements (select at least one):

    out of 6000

    out of 6000

Appendix I: Financial Accountability

I-3: Payment (3 of 7)

  1. Supplemental or Enhanced Payments. Section 1902(a)(30) requires that payments for services be consistent with efficiency, economy, and quality of care. Section 1903(a)(1) provides for Federal financial participation to States for expenditures for services under an approved State plan/waiver. Specify whether supplemental or enhanced payments are made. Select one:

    out of 6000

Appendix I: Financial Accountability

I-3: Payment (4 of 7)

  1. Payments to State or Local Government Providers. Specify whether State or local government providers receive payment for the provision of waiver services.

    Do not complete Item I-3-e.
    Complete Item I-3-e.

    out of 4000

Appendix I: Financial Accountability

I-3: Payment (5 of 7)

  1. Amount of Payment to State or Local Government Providers.

    Specify whether any State or local government provider receives payments (including regular and any supplemental payments) that in the aggregate exceed its reasonable costs of providing waiver services and, if so, whether and how the State recoups the excess and returns the Federal share of the excess to CMS on the quarterly expenditure report. Select one:

    out of 6000

Appendix I: Financial Accountability

I-3: Payment (6 of 7)

  1. Provider Retention of Payments. Section 1903(a)(1) provides that Federal matching funds are only available for expenditures made by states for services under the approved waiver. Select one:

    out of 12000

    out of 12000

Appendix I: Financial Accountability

I-3: Payment (7 of 7)

  1. Additional Payment Arrangements

    1. Voluntary Reassignment of Payments to a Governmental Agency. Select one:

      out of 4000
    2. Organized Health Care Delivery System. Select one:

      out of 18000
    3. Contracts with MCOs, PIHPs or PAHPs. Select one:

      out of 18000

Appendix I: Financial Accountability

I-4: Non-Federal Matching Funds (1 of 3)

  1. State Level Source(s) of the Non-Federal Share of Computable Waiver Costs. Specify the State source or sources of the non-federal share of computable waiver costs. Select at least one:

    out of 6000

    out of 6000

Appendix I: Financial Accountability

I-4: Non-Federal Matching Funds (2 of 3)

  1. Local Government or Other Source(s) of the Non-Federal Share of Computable Waiver Costs. Specify the source or sources of the non-federal share of computable waiver costs that are not from state sources. Select One:

    . There are no local government level sources of funds utilized as the non-federal share.
    Check each that applies:

    out of 6000

    out of 6000

Appendix I: Financial Accountability

I-4: Non-Federal Matching Funds (3 of 3)

  1. Information Concerning Certain Sources of Funds. Indicate whether any of the funds listed in Items I-4-a or I-4-b that make up the non-federal share of computable waiver costs come from the following sources: (a) health care-related taxes or fees; (b) provider-related donations; and/or, (c) federal funds. Select one:

    Check each that applies:

    out of 6000

Appendix I: Financial Accountability

I-5: Exclusion of Medicaid Payment for Room and Board

  1. Services Furnished in Residential Settings. Select one:

  2. Method for Excluding the Cost of Room and Board Furnished in Residential Settings.

    out of 12000

Appendix I: Financial Accountability

I-6: Payment for Rent and Food Expenses of an Unrelated Live-In Caregiver

Reimbursement for the Rent and Food Expenses of an Unrelated Live-In Personal Caregiver. Select one:

out of 6000

Appendix I: Financial Accountability

I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (1 of 5)

  1. 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:

    1. Co-Pay Arrangement.

      Specify the types of co-pay arrangements that are imposed on waiver participants (check each that applies):

      Charges Associated with the Provision of Waiver Services (if any are checked, complete Items I-7-a-ii through I-7-a-iv):

      out of 6000

Appendix I: Financial Accountability

I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (2 of 5)

  1. Co-Payment Requirements.

    1. Participants Subject to Co-pay Charges for Waiver Services.

      Answers provided in Appendix I-7-a indicate that you do not need to complete this section.

Appendix I: Financial Accountability

I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (3 of 5)

  1. Co-Payment Requirements.

    1. Amount of Co-Pay Charges for Waiver Services.

      Answers provided in Appendix I-7-a indicate that you do not need to complete this section.

Appendix I: Financial Accountability

I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (4 of 5)

  1. Co-Payment Requirements.

    1. Cumulative Maximum Charges.

      Answers provided in Appendix I-7-a indicate that you do not need to complete this section.

Appendix I: Financial Accountability

I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (5 of 5)

  1. Other State Requirement for Cost Sharing. Specify whether the State imposes a premium, enrollment fee or similar cost sharing on waiver participants. Select one:

    out of 12000

Appendix J: Cost Neutrality Demonstration

J-1: Composite Overview and Demonstration of Cost-Neutrality Formula

Composite Overview.

Nursing Facility

Col. 1 Col. 2 Col. 3 Col. 4 Col. 5 Col. 6 Col. 7 Col. 8
Year Factor D Factor D' Total: D+D' Factor G Factor G' Total: G+G' Difference (Col 7 less Column4)
1 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

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (1 of 9)

  1. Number Of Unduplicated Participants Served. Enter the total number of unduplicated participants from Item B-3-a who will be served each year that the waiver is in operation. When the waiver serves individuals under more than one level of care, specify the number of unduplicated participants for each level of care:

    Table: J-2-a: Unduplicated Participants
    Waiver Year Total Unduplicated Number of Participants (from Item B-3-a) Distribution of Unduplicated Participants by Level of Care (if applicable)
    Level of Care:
    Nursing Facility
    Year 1 2548
    Year 2 5146
    Year 3 7397
    Year 4 7118
    Year 5 7688

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (2 of 9)

  1. Average Length of Stay.

    out of 6000

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (3 of 9)

  1. Derivation of Estimates for Each Factor. Provide a narrative description for the derivation of the estimates of the following factors.

    1. out of 12000
    2. out of 12000
    3. out of 12000
    4. out of 12000

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (4 of 9)

Component management for waiver services. If the service(s) below includes two or more discrete services that are reimbursed separately, or is a bundled service, each component of the service must be listed. Select “manage components” to add these components.

Waiver Services
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

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (5 of 9)

  1. 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/ ComponentCapi-tationUnit# UsersAvg. Units Per UserAvg. Cost/ UnitComponent CostTotal 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
GRAND TOTAL: 33990472.66
Total: Services included in capitation:
Total: Services not included in capitation: 33990472.66
Total Estimated Unduplicated Participants: 2548
Factor D (Divide total by number of participants): 13340.06
Services included in capitation:
Services not included in capitation: 13340.06
Average Length of Stay on the Waiver:

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (6 of 9)

  1. 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/ ComponentCapi-tationUnit# UsersAvg. Units Per UserAvg. Cost/ UnitComponent CostTotal 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
GRAND TOTAL: 59963902.40
Total: Services included in capitation:
Total: Services not included in capitation: 59963902.40
Total Estimated Unduplicated Participants: 5146
Factor D (Divide total by number of participants): 11652.53
Services included in capitation:
Services not included in capitation: 11652.53
Average Length of Stay on the Waiver:

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (7 of 9)

  1. 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/ ComponentCapi-tationUnit# UsersAvg. Units Per UserAvg. Cost/ UnitComponent CostTotal 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
GRAND TOTAL: 99939758.84
Total: Services included in capitation:
Total: Services not included in capitation: 99939758.84
Total Estimated Unduplicated Participants: 7397
Factor D (Divide total by number of participants): 13510.85
Services included in capitation:
Services not included in capitation: 13510.85
Average Length of Stay on the Waiver:

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (8 of 9)

  1. 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/ ComponentCapi-tationUnit# UsersAvg. Units Per UserAvg. Cost/ UnitComponent CostTotal 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
GRAND TOTAL: 99472016.08
Total: Services included in capitation:
Total: Services not included in capitation: 99472016.08
Total Estimated Unduplicated Participants: 7118
Factor D (Divide total by number of participants): 13974.71
Services included in capitation:
Services not included in capitation: 13974.71
Average Length of Stay on the Waiver:

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (9 of 9)

  1. 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/ ComponentCapi-tationUnit# UsersAvg. Units Per UserAvg. Cost/ UnitComponent CostTotal 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
GRAND TOTAL: 140411418.14
Total: Services included in capitation:
Total: Services not included in capitation: 140411418.14
Total Estimated Unduplicated Participants: 7688
Factor D (Divide total by number of participants): 18263.71
Services included in capitation:
Services not included in capitation: 18263.71
Average Length of Stay on the Waiver: