CMS-10398-10 Long Term Services and Supports Form

Long Term Services and Supports Form

Please complete this form if you indicated in Section III that the Demonstration will provide long term services and supports (LTSS).

Indicate the Population(s) that the following long-term services and support description applies to:

[Add Populations Here]

Administration of the Long Term Services and Supports Program

Will the LTSS component of the Demonstration be operated by one or more State agencies other than the Medicaid agency? Yes No

If yes, please provide the contact information of the key contacts at those agencies, including name, title, name of agency, address, telephone number, email address and fax number. Also describe the specific sub-population associated with the contact:

Do other State agencies, that are not part of the Single State Medicaid Agency, perform Demonstration operational and administrative functions on behalf of the Medicaid agency?

Yes No

Do any contracted entities, including managed care organizations, perform Demonstration operational and administrative functions on behalf of the Medicaid agency or the waiver operating agency (if applicable)?

Yes No

Do any local or regional non-state entities perform Demonstration operational and administrative functions?

Yes No

If yes to any of the questions above, specify the types of State agencies, contracted entities and/or local/regional non-state entities and describe the specific functions that they perform. This includes individual enrollment, management of any enrollment or expenditure limits, level of care evaluation, review of service plans, prior authorization of services, utilization management, provider enrollment and agreements, rate methodologies, rules, policies and procedures, and quality assurance and improvement activities. Please describe how the Single State Agency oversees the performance of these non-State entities:

Consolidation of Existing Waivers or Authorities into the Demonstration

Are existing State waivers or programs operating under other authorities are being consolidated into the Demonstration Program?

Yes No

If yes, identify the existing waiver(s) (1915(b),(c),(d),(e) or State Plan authorities (1915(a), (i), (j), (k), 1932) that are being consolidated into the 1115 Demonstration, including the names of the waivers or programs and identifying waiver numbers. Also indicate the current status of these waivers or authorities.

Describe how individuals in these programs will be transitioned to the 1115 Demonstration program and assured a comparable level of services, quality and continuity of care.

Level of Care to Qualify for the Program

This Demonstration is requested in order to provide LTSS to individuals who, but for the provision of such services, would require the following level(s) of care, the costs of which should be reimbursed under the approved Medicaid state plan:

Indicate and describe the level of care criteria for participants in the Long Term Services and Supports Demonstration program, such as hospital, nursing facility, ICF-MR, IMD-hospital, IMD-nursing facility, or needs-based criteria. Identify which entity performs the initial and subsequent level of care evaluations and the frequency of such reevaluations:

Individual Cost Limits

Do individual cost limits apply when determining whether to deny LTSS or entrance to the Demonstration to an otherwise eligible individual? Yes No

If yes, indicate the type of cost limit that applies and describe any additional requirements pertaining to the indicated limit:

Cost Limit in Excess of Institutional Costs. The State refuses entrance to the Demonstration to any otherwise eligible individual when the State reasonably expects that the cost of the LTSS furnished to that individual would exceed the cost of a level of care specified for the Demonstration up to an amount specified by the State.

Institutional Cost Limit. The State refuses entrance to the Demonstration to any otherwise eligible individual when the State reasonably expects that the cost of the LTSS furnished to that individual would exceed 100% of the cost of the level of care specified for the waiver.

Cost Limit Lower Than Institutional Costs. The State refuses entrance to the Demonstration to any otherwise qualified individual when the State reasonably expects that the cost of LTSS furnished to that individual would exceed an amount specified by the State that is less than the cost of a level of care specified for the Demonstration. Specify the basis of the limit, including evidence that the limit is sufficient to assure the health and welfare of Demonstration individuals.

Long Term Services and Supports – Outreach, Education, Enrollment and Screening

Describe the Demonstration program’s approach to Outreach, Education, Enrollment and Screening, including any coordination with a Money Follows the Person program. Include a description of the roles of the State and other entities in the processes.

Person-Centered Planning

Indicate who is responsible for collaborating with the individual in developing the Demonstration's person-centered service plan and for its final development:

Case Manager Social Worker

Other (please describe, include qualifications)

Supporting the Participant in Service Plan Development

Specify: (a) the supports and information that are made available to the individual (and/or family or legal representative, as appropriate) to direct and be actively engaged in the service plan development process and (b) the individual’s authority to determine who is included in the process.

Service Plan Development Process

Describe the process that is used to develop the person-centered service plan, including:

1. who develops the plan, what individuals are expected to participate in the plan development process;

2. the timing of the plan, how and when it is updated, including mechanisms to address changing circumstances and needs (and expectations regarding scheduling and location of meetings to accommodate individuals receiving services);

3. the types of assessments that are conducted to support the service plan development process, including securing information about the individual's needs, preferences and goals, and health status;

4. how the individual is informed of the services that are available under the Demonstration;

5. how the plan development process ensures that the service plan addresses the individual's goals, needs (including health care needs), and preferences;

6. how Demonstration and other services are coordinated;

7. how the plan development process provides for the assignment of responsibilities to implement and monitor the plan;

8. Indicate how and when the plan is updated, in addition to when the individual’s needs change;

9. indicate the frequency with which the service plan is reviewed and the service delivery oversight process; and

(j) Indicate whether the Demonstration allows for self-direction by budget, hire/fire authority or both.

Criminal History and/or Background Investigations

Specify the State’s policies concerning the conduct of criminal history and/or background investigations of individuals who provide Demonstration services:

Are criminal history and/or background investigations required? Yes No

If yes, indicate the types of positions for which such investigations must be conducted:

Administrative Staff Transport Staff

Staff, providers and others who have direct contact with the individual

Others (please describe)

Indicate the scope of such investigations:

National (FBI) criminal records check State criminal records check only

Other (please describe)

Abuse Registry Screening

Does the State maintains an abuse registry and requires the screening of individuals through this registry? Yes No

If yes, specify the entity (entities) responsible for maintaining the abuse registry:

Indicate the types of positions for which abuse registry screenings must be conducted:

Administrative Staff Transport Staff

Staff, providers and others who have direct contact with the individual

Others (please describe)

Allowable Settings

Are Demonstration services provided in facilities subject to §1616(e) of the Act?

Yes No

If yes, indicate the types of facilities where Demonstration services may be provided, any capacity limits for such facilities, the home and community based services that may be provided in such facilities, and how a home and community character is maintained in these settings.

Individual Rights

In addition to fair hearings, does the State operate other systems for dispute resolution, grievances or complaints concerning the operation of the Demonstration program’s home and community-based services component?

Yes No

Quality Improvement Strategies

Provide a description of the quality improvement strategies to be employed in the operation of the Demonstration. In particular describe strategies to ensure the health and welfare of individuals to be served with Home and Community-Based Services, including the prevention of abuse, neglect and exploitation (e.g., critical incident management system, utilization review, case management visits, etc.), the single State Medicaid Agency oversight and involvement. Please also include the self-direction strategy if the Demonstration allows for self-direction.

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