Enclosure _____
State of ______________
1915(j) Self-Directed Personal Assistance Services State Plan Amendment Pre-Print
Citation 3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy (Continued)
1915(j)
_____ Self-Directed Personal Assistance Services, as described and limited in Supplement ____ to Attachment 3.1‑A.
ATTACHMENT 3.1‑A identifies the medical and remedial services provided to the categorically needy.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-NEW. The time required to complete this information collection is estimated to average 20 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Enclosure ___
State of ______________
1915(j) Self-Directed Personal Assistance Services State Plan Amendment Pre-Print
Citation 3.1(a)(2) Amount, Duration, and Scope of Services: Medically Needy (Continued)
1915(j)
____ Self-Directed Personal Assistance Services, as described and limited in Supplement _____ to Attachment 3.1‑B.
ATTACHMENT 3.1‑B identifies medical and remedial services provided to each covered group of the medically needy.
Enclosure ___
Attachment 3.1‑A
State of ______________
1915(j) Self-Directed Personal Assistance Services State Plan Amendment Pre-Print
Amount, Duration and Scope of Medical and Remedial Care Services Provided To the Categorically Needy
___. Self-Directed Personal Assistance Services, as described in Supplement ___ to Attachment 3.1‑A.
____ Election of Self-Directed Personal Assistance Services: By virtue of this submittal, the State elects Self-Directed Personal Assistance Services as a State Plan service delivery option.
____ No election of Self-Directed Personal Assistance Services: By virtue of this submittal, the State elects not to add Self-Directed Personal Assistance Services as a State Plan service delivery option.
Enclosure ___
Attachment 3.1‑B
State of ________
1915(j) Self-Directed Personal Assistance Services State Plan Amendment Pre-Print
Amount, Duration and Scope of Medical and Remedial Care Services Provided To the Medically Needy
___. Self-Directed Personal Assistance Services, as described in Supplement ___ to Attachment 3.1‑B.
____ Election of Self-Directed Personal Assistance Services: By virtue of this submittal, the State elects Self-Directed Personal Assistance Services as a State Plan service delivery option.
____ No election of Self-Directed Personal Assistance Services: By virtue of this submittal, the State elects not to add Self-Directed Personal Assistance Services as a State Plan service delivery option.
Enclosure ____
Supplement ____ to Attachment 3.1‑A
Notwithstanding anything else in this State Plan provision, the coverage will be subject to such other requirements that are promulgated by CMS through interpretive issuance or final regulation.
State of ______________
1915(j) Self-Directed Personal Assistance Services State Plan Amendment Pre-Print
Eligibility
The State determines eligibility for Self-Directed Personal Assistance Services:
_____In the same manner as eligibility is determined for traditional State Plan personal care services, described in Item 24 of the Medicaid State Plan.
_____In the same manner as eligibility is determined for services provided through a 1915(c) Home and Community-Based Services Waiver.
Service Package
The State elects to have the following included as Self-Directed Personal Assistance Services:
_____ State Plan Personal Care and Related Services, to be self-directed by individuals eligible under the State Plan.
_____ Services included in the following Section 1915(c) Home and Community-Based Services waiver(s) to be self directed by individuals eligible under the waiver(s). The State assures that all services in the impacted waiver(s) will continue to be provided regardless of service delivery model. Please list waiver names and services to be included.
Payment Methodology
_____Payment rates will be calculated using the approved State plan personal care services rate or section 1915(c) Home and Community-Based waiver services rate.
_____The State will use a different reimbursement methodology for individuals self-directing their PAS under section 1915(j) than that approved for State plan personal care services or for section 1915(c) Home and Community-Based waiver services. Amended Attachment 4.19-B page(s) are attached.
Use of Cash
_____ The State elects to disburse cash prospectively to participants self-directing personal assistance services. The State assures that all Internal Revenue Service (IRS) requirements regarding the disbursement of cash will be followed.
_____ The State elects not to disburse cash prospectively to participants self-directing personal assistance services.
Voluntary Disenrollment
The State will provide the following safeguards in place to ensure continuity of services and assure participant health and welfare during the period of transition between self-directed and traditional services.
Involuntary Disenrollment
The circumstances under which a participant may be involuntarily disenrolled from self-directing personal assistance services, and returned to traditional services are noted below.
The State will provide the following safeguards in place to ensure continuity of services and assure participant health and welfare during the period of transition between self-directed and traditional services.
Participant Living Arrangement
Any additional restrictions on participant living arrangements, other than homes or property owned, operated or controlled by a provider of services, not related by blood or marriage to the participant are noted below.
Geographic Limitations and Comparability
_____ The State elects to provide self-directed personal assistance services on a statewide basis.
_____ The State elects to provide self-directed personal assistance services on a targeted geographic basis. Please describe:_______________________________
_____ The State elects to provide self-directed personal assistance services to all eligible populations.
_____ The State elects to provide self-directed personal assistance services to targeted populations. Please describe: __________________________________
_____ The State elects to provide self-directed personal assistance services to an unlimited number of participants.
_____ The State elects to provide self-directed personal assistance services to _________ (insert number of) participants, at any given time.
Assurances
The State assures that there are traditional services, comparable in amount, duration and scope, to self-directed personal assistance services.
The State assures that there are necessary safeguards in place to protect the health and welfare of individuals provided services under this State Plan Option, and to assure financial accountability for funds expended for self-directed personal assistance services.
The State assures that an evaluation will be performed of participants’ need for personal assistance services for individuals who meet the following requirements:
Are entitled to medical assistance for personal care services under the Medicaid State Plan; or
Are entitled to and are receiving home and community-based services under a Section 1915(c) waiver; or
May require self-directed personal assistance services; or
May be eligible for self-directed personal assistance services.
The State assures that individuals are informed of all options for receiving self-directed and/or traditional State Plan personal care services or personal assistance services provided under a Section 1915(c) waiver, including information about self-direction opportunities that is sufficient to inform decision-making about the election of self-direction and provided on a timely basis to individuals or their representatives.
The State assures that a support system will be provided to individuals that meets the following:
Appropriately assesses and counsels individuals prior to enrollment;
Provides appropriate counseling, information, training and assistance to ensure that participants are able to manage their services and budgets;
Offers additional counseling, information, training or assistance, including financial management services:
At the request of the participant for any reason; or
When the State has determined the participant is not effectively managing their services identified in their service plans or budgets.
The State assures that an annual report will be provided to CMS on the number of individuals served through this State Plan Option and total expenditures on their behalf, in the aggregate.
The State assures that an evaluation will be provided to CMS every three years, describing the overall impact of this State Plan Option on the health and welfare of participating individuals, compared to individuals not self-directing their personal assistance services.
The State assures that the provisions of Section 1902(a)(27) of the Social Security Act, and 42 CFR 431.107, governing provider agreements, are met.
The State assures that a service plan and service budget will be developed for each individual receiving self-directed PAS. These are developed based on the assessment of needs.
The State assures that the methodology used to establish service budgets will meet the following criteria:
Objective and evidence based, utilizing valid, reliable cost data.
Applied consistently to participants.
Open for public inspection.
Includes a calculation of the expected cost of the self-directed PAS and supports if those services and supports were not self-directed.
Includes a process for any limits placed on self-directed services and supports and the basis/bases for the limits.
Includes any adjustments that will be allowed and the basis/bases for the adjustments.
Includes procedures to safeguard participants when the amount of the limit on services is insufficient to meet a participant’s needs.
Includes a method of notifying participants of the amount of any limit that applies to a participant’s self-directed PAS and supports.
Does not restrict access to other medically necessary care and services furnished under the plan and approved by the State but not included in the budget.
Service Plan
The State has the following safeguards in place, to permit entities providing other Medicaid State Plan services to be responsible for developing the self-directed personal assistance services service plan, to assure that the service provider’s influence on the planning process is fully disclosed to the participant and that procedures are in place to mitigate that influence.
Quality Assurance and Improvement Plan
The State’s quality assurance and improvement plan is described below, including
How it will conduct activities of discovery, remediation and quality improvement in order to ascertain whether the program meets assurances, corrects shortcomings, and pursues opportunities for improvement; and
The system performance measures, outcome measures and satisfaction measures that the State will monitor and evaluate.
Risk Management
The risk assessment methods used to identify potential risks to participants are described below.
The tools or instruments used to mitigate identified risks are described below.
The State’s process for ensuring that each service plan reflects the risks that an individual is willing and able to assume, and the plan for how identified risks will be mitigated, is described below.
The State’s process for ensuring that the risk management plan is the result of discussion and negotiation among the persons designated by the State to develop the service plan, the participant, the participant’s representative, if any, and others from whom the participant may seek guidance, is described below.
Qualifications of Providers of Personal Assistance
_____ The State elects to permit participants to hire legally liable relatives, as paid providers of the personal assistance services identified in the service plan and budget.
_____ The State elects not to permit participants to hire legally liable relatives, as paid providers of the personal assistance services identified in the service plan and budget.
Use of a Representative
_____ The State elects to permit participants to appoint a representative to direct the provision of self-directed personal assistance services on their behalf.
_____ The State elects to include, as a type of representative, a State-mandated representative. Please indicate the criteria to be applied.
_____ The State elects not to permit participants to appoint a representative to direct the provision of self-directed personal assistance services on their behalf.
Permissible Purchases
_____ The State elects to permit participants to use their service budgets to pay for items that increase a participant’s independence or substitute for a participant’s dependence on human assistance.
_____ The State elects not to permit participants to use their service budgets to pay for items that increase a participant’s independence or substitute for a participant’s dependence on human assistance.
Financial Management Services
_____ The State elects to employ a Financial Management Entity to provide financial management services to participants self-directing personal assistance services, with the exception of those participants utilizing the cash option and performing those functions themselves.
____ The State elects to provide financial management services through a reporting or subagent through its fiscal intermediary in accordance with Section 3504 of the IRS Code and Revenue Procedure 80-4 and Notice 2003-70; or
____ The State elects to provide financial management services through vendor organizations that have the capabilities to perform the required tasks in accordance with Section 3504 of the IRS Code and Revenue Procedure 70-6. (When private entities furnish financial management services, the procurement method must meet the requirements set forth in 45 CFR Section 74.40 – Section 74.48.)
____ The State elects to provide financial management services using “agency with choice” organizations that have the capabilities to perform the required tasks in accordance with the principles of self-direction and with Federal and State Medicaid rules.
_____ The State elects to directly perform financial management services on behalf of participants self-directing personal assistance services, with the exception of those participants utilizing the cash option and performing those functions themselves.
Enclosure ____
Supplement ____ to Attachment 3.1‑B
Notwithstanding anything else in this State Plan provision, the coverage will be subject to such other requirements that are promulgated by CMS through interpretive issuance or final regulation.
State of ______________
1915(j) Self-Directed Personal Assistance Services State Plan Amendment Pre-Print
Eligibility
The State determines eligibility for Self-Directed Personal Assistance Services:
_____In the same manner as eligibility is determined for traditional State Plan personal care services, described in Item 24 of the Medicaid State Plan.
_____In the same manner as eligibility is determined for services provided through a 1915(c) Home and Community-Based Services Waiver.
Service Package
The State elects to have the following included as Self-Directed Personal Assistance Services:
_____ State Plan Personal Care and Related Services, to be self-directed by individuals eligible under the State Plan.
_____ Services included in the following Section 1915(c) Home and Community-Based Services waiver(s) to be self directed by individuals eligible under the waiver(s). The State assures that all services in the impacted waiver(s) will continue to be provided regardless of service delivery model. Please list waiver names and services to be included.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-NEW. The time required to complete this information collection is estimated to average 20 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Payment Methodology
_____Payment rates will be calculated using the approved State plan personal care services rate or section 1915(c) Home and Community-Based waiver services rate.
_____The State will use a different reimbursement methodology for individuals self-directing their PAS under section 1915(j) than that approved for State plan personal care services or for section 1915(c) Home and Community-Based waiver services. Amended Attachment 4.19-B page(s) are attached.
Use of Cash
_____ The State elects to disburse cash prospectively to participants self-directing personal assistance services. The State assures that all Internal Revenue Service (IRS) requirements regarding the disbursement of cash will be followed.
_____ The State elects not to disburse cash prospectively to participants self-directing personal assistance services.
Voluntary Disenrollment
The State will provide the following safeguards in place to ensure continuity of services and assure participant health and welfare during the period of transition between self-directed and traditional services.
Involuntary Disenrollment
The circumstances under which a participant may be involuntarily disenrolled from self-directing personal assistance services, and returned to traditional services are noted below.
The State will provide the following safeguards in place to ensure continuity of services and assure participant health and welfare during the period of transition between self-directed and traditional services.
Participant Living Arrangement
Any additional restrictions on participant living arrangements, other than homes or property owned, operated or controlled by a provider of services, not related by blood or marriage to the participant, are noted below.
Geographic Limitations and Comparability
_____ The State elects to provide self-directed personal assistance services on a statewide basis.
_____ The State elects to provide self-directed personal assistance services on a targeted geographic basis. Please describe: _______________________________
_____ The State elects to provide self-directed personal assistance services to all eligible populations.
_____ The State elects to provide self-directed personal assistance services to targeted populations. Please describe: __________________________________
_____ The State elects to provide self-directed personal assistance services to an unlimited number of participants.
_____ The State elects to provide self-directed personal assistance services to _________ (insert number of) participants, at any given time.
Assurances
The State assures that there are traditional services, comparable in amount, duration and scope, to self-directed personal assistance services.
The State assures that there are necessary safeguards in place to protect the health and welfare of individuals provided services under this State Plan Option, and to assure financial accountability for funds expended for self-directed personal assistance services.
The State assures that an evaluation will be performed of participants’ need for personal assistance services for individuals who meet the following requirements:
Are entitled to medical assistance for personal care services under the Medicaid State Plan; or
Are entitled to and are receiving home and community-based services under a Section 1915(c) waiver; or
May require self-directed personal assistance services; or
May be eligible for self-directed personal assistance services.
The State assures that individuals are informed of all options for receiving self-directed and/or traditional State Plan personal care services or personal assistance services provided under a Section 1915(c) waiver, including information about self-direction opportunities that is sufficient to inform decision-making about the election of self-direction and provided on a timely basis to individuals or their representatives.
The State assures that a support system will be provided to individuals that meets the following:
Appropriately assesses and counsels individuals prior to enrollment;
Provides appropriate counseling, information, training and assistance to ensure that participants are able to manage their services and budgets;
Offers additional counseling, information, training or assistance, including financial management services:
At the request of the participant for any reason; or
When the State has determined the participant is not effectively managing their services identified in their service plans or budgets.
The State assures that an annual report will be provided to CMS on the number of individuals served through this State Plan Option and total expenditures on their behalf, in the aggregate.
The State assures that an evaluation will be provided to CMS every three years, describing the overall impact of this State Plan Option on the health and welfare of participating individuals, compared to individuals not self-directing their personal assistance services.
The State assures that the provisions of Section 1902(a)(27) of the Social Security Act, and 42 CFR 431.107, governing provider agreements, are met.
The State assures that a service plan and service budget will be developed for each individual receiving self-directed PAS. These are developed based on the assessment of needs.
The State assures that the methodology used to establish service budgets will meet the following criteria:
Objective and evidence based, utilizing valid, reliable cost data.
Applied consistently to participants.
Open for public inspection.
Includes a calculation of the expected cost of the self-directed PAS and supports if those services and supports were not self-directed.
Includes a process for any limits placed on self-directed services and supports and the basis/bases for the limits.
Includes any adjustments that will be allowed and the basis/bases for the adjustments.
Includes procedures to safeguard participants when the amount of the limit on services is insufficient to meet a participant’s needs.
Includes a method of notifying participants of the amount of any limit that applies to a participant’s self-directed PAS and supports.
Does not restrict access to other medically necessary care and services furnished under the plan and approved by the State but not included in the budget.
Service Plan
The State has the following safeguards in place, to permit entities providing other Medicaid State Plan services to be responsible for developing the self-directed personal assistance services service plan, to assure that the service provider’s influence on the planning process is fully disclosed to the participant and that procedures are in place to mitigate that influence.
Quality Assurance and Improvement Plan
The State’s quality assurance and improvement plan is described below, including
How it will conduct activities of discovery, remediation and quality improvement in order to ascertain whether the program meets assurances, corrects shortcomings, and pursues opportunities for improvement; and
The system performance measures, outcome measures and satisfaction measures that the State will monitor and evaluate.
Risk Management
The risk assessment methods used to identify potential risks to participants are described below.
The tools or instruments used to mitigate identified risks are described below.
The State’s method of ensuring that each service plan reflects the risks that an individual is willing and able to assume, and the plan for how identified risks will be mitigated is described below.
The State’s method for ensuring that the risk management plan is the result of discussion and negotiation among the persons designated by the State to develop the service plan, the participant, the participant’s representative, if any, and others from whom the participant may seek guidance, is described below.
Qualifications of Providers of Personal Assistance
_____ The State elects to permit participants to hire legally liable relatives, as paid providers of the personal assistance services identified in the service plan and budget.
_____ The State elects not to permit participants to hire legally liable relatives, as paid providers of the personal assistance services identified in the service plan and budget.
Use of a Representative
_____ The State elects to permit participants to appoint a representative to direct the provision of self-directed personal assistance services on their behalf.
_____ The State elects to include, as a type of representative, a State-mandated representative. Please indicate the criteria to be applied.
_____ The State elects not to permit participants to appoint a representative to direct the provision of self-directed personal assistance services on their behalf.
Permissible Purchases
_____ The State elects to permit participants to use their service budgets to pay for items that increase a participant’s independence or substitute for a participant’s dependence on human assistance.
_____ The State elects not to permit participants to use their service budgets to pay for items that increase a participant’s independence or substitute for a participant’s dependence on human assistance.
Financial Management Services
_____ The State elects to employ a Financial Management Entity to provide financial management services to participants self-directing personal assistance services, with the exception of those participants utilizing the cash option and performing those functions themselves.
____ The State elects to provide financial management services through a reporting or subagent through its fiscal intermediary in accordance with Section 3504 of the IRS Code and Revenue Procedure 80-4 and Notice 2003-70; or
____ The State elects to provide financial management services through vendor organizations that have the capabilities to perform the required tasks in accordance with Section 3504 of the IRS Code and Revenue Procedure 70-6. (When private entities furnish financial management services, the procurement method must meet the requirements set forth in 45 CFR Section 74.40 – Section 74.48.)
____ The State elects to provide financial management services using “agency with choice” organizations that have the capabilities to perform the required tasks in accordance with the principles of self-direction and with Federal and State Medicaid rules.
B._____ The State elects to directly perform financial management services on behalf of participants self-directing personal assistance services, with the exception of those participants utilizing the cash option and performing those functions themselves.
| File Type | application/msword |
| File Title | Enclosure 3 |
| Author | HCFA Software Control |
| Last Modified By | CMS |
| File Modified | 2007-05-09 |
| File Created | 2007-05-09 |