Form CMS-10412 Section 1115 Demonstration Application Template

Section 1115 Demonstration

Long Term Services and Supports and Other Service Models for Individuals with Disabilities and Chronic Conditions

APPLICATION TEMPLATE

OMB Control No: 0938-New, Expiration Date: XXXX

______________________________________________________________________________

Instructions: Throughout the template you will see <instructions>, please complete with information that is unique to the State’s LTSS demonstration request.

Demonstration applications may be submitted via electronic mail to [email protected] or via mail to:

Ms. Victoria Wachino

Centers for Medicare and Medicaid Services

Children and Adults Health Programs Group

Mail Stop: S2-1-16

7500 Security Boulevard

Baltimore, MD 21244

PRA Disclosure Statement

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 application is estimated to average 40 hours per response, including the time to review instructions and complete/submit the State Medicaid Agency Cover Letter; Project Abstract; Letters of Agreement, Endorsements and Support; Application Narrative; Preliminary Work Plan; Proposed Budget (using the Informational Financial Reporting Form in Attachment B); and the Final Work Plan. 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.

The <insert State name>, <insert Medicaid State Agency name>, proposes this demonstration under the authority of section 1115(a) of the Social Security Act (the Act). This demonstration is for the purpose of enabling States to provide Home and Community Based Services as interventions to prevent or delay institutional utilization.

State Name:

State Medicaid Director Name:

Telephone Number:

E-mail Address:

Other Key Contacts:

The State information above identifies contact information for CMS to use in discussing demonstration applications as necessary. Please describe State operational and administrative strategies if agencies in addition to the Single State Agency will participate in operation of demonstration program:

<insert goal(s)>

General Description Of Program

The Long Term Services and Supports section 1115(a) Demonstration expands the array of services and techniques states may use to increase access to HCBS, improve care for individuals and help States to reduce costly utilization of institutional services. All Medicaid requirements apply, except to the extent waived or specifically identified as not applicable.

<Please provide a description of the State’s program, including brief mention of delivery system and stakeholder engagement strategy, HCBS waivers (by number and title) to be subsumed, in whole or in part, in the demonstration >

The Demonstration will affect the following eligibility group(s):

Eligibility Group Name	Description	FPL
<insert eligibility group name> Example: Group A	<insert eligibility group description> Example: Adults between the ages of 21 and 64.	<insert FPL level for eligibility for Group A> Example: Above 100% but below 133%
<insert eligibility group name> Example: Group B	<insert eligibility group description> Example: Premium assistance	<insert FPL level for Group B> Example: Above 133% but below 250%

State’s goals in implementing the Demonstration are:

<insert goal(s)>

State’s Strategy and Efforts for Public Input and Stakeholder engagement are:

<insert strategy for public input and stakeholder engagement, both initially and ongoing>

Demonstration Eligibility and Benefits

1. Populations Affected by the Demonstration.

□ Individuals described below who are included in an eligibility group under the State plan are subject to all applicable Medicaid laws and regulations, except to the extent expressly waived, in the list of waivers issued with the award letter for this Demonstration.

□ Individuals described below who are eligible for benefits only through this Demonstration, by virtue of the expenditure authorities expressly granted in this Demonstration, are subject to Medicaid laws or regulations except to the extent as identified as not applicable.

<please describe>

Demonstration Population Name	Description	FPL
<insert group name> Example: Group A	<insert group description> Example: Adults between the ages of 21 and 64.	<insert FPL level for for Group A> Example: Above 100% but below 133%
<insert group name> Example: Group B	<insert group description> Example: Adults between the ages of 21 and 65	<insert FPL level for Group B> Example: Above 133% but below 250%

2. Eligibility Exclusions (if applicable). The following persons, who are otherwise eligible under the criteria in paragraph 1, are excluded from the LTSS Demonstration.

<insert maximum FPL level or other exclusionary criteria>

3. Demonstration Benefits. Individuals eligible under the State plan continue to be provided the full Medicaid benefit package, except as waived in the waiver list. Some or all benefits for such individuals, as described below, may be delivered through the Demonstration service delivery system subject to the conditions, limitations or procedures described below. Demonstration-only benefits for individuals eligible by virtue of this Demonstration may include some or all of the full Medicaid package, as described below. Demonstration-only benefits for all populations affected by the Demonstration include a foundation of home and community based services, supplemented with care coordination and linkages to acute, primary and behavioral health services and integration of those services. The benefit package will also include institutional benefits for those individuals for whom HCBS, provided in community based settings, would not be appropriate to assure health and welfare.

The benefit package may also include services authorized under Title XIX and Section 2703 of the Affordable Care Act. States wishing to include a health home model within this demonstration may do so in accordance with provisions of Section 1945 (if including a health home program under the demonstration, please complete description below).

The following categories of services are covered:

<insert all benefit categories and descriptions to be included in the demonstration>

The State proposes to offer a health home program consistent with Section 2703 of the Affordable Care Act. Please indicate in the description below if the State intends to limit the benefit to particular age groups or exclude particular groups.

<please describe the State’s proposed Health Home program>

General Category of Service	Specific Services Include	Population Served
Basic Medicaid Benefits Example: Home and Community Based Services	Example: Array of services to meet individual needs in home and community based settings (for example, personal care, environmental modifications, medication management, etc). Note: MFP and Community First Choice Options must be identified distinctly from general HCBS category.

The following categories of services not included in the participant benefit package. <enter all excluded benefit categories, if applicable>

General Category of Service	Services Do Not Include

Person Centered Planning

<insert person-centered planning strategy>

SAMPLE:

Person-Centered Planning. The State will utilize a person-centered and directed planning process, intended to identify the strengths, capacities, preferences, needs, and desired outcomes of the participant. A person centered plan is developed with the assistance of the team and those individuals the participant chooses to include. The plan includes the services and supports that the participant needs to live in the community. A back-up plan must be developed and incorporated into the plan to assure that the needed assistance will be provided in the event that the regular services and supports identified in the ISSP are temporarily unavailable. The back-up plan may include other individual assistants or agency services. The State shall have a process that permits participants to request a change to the person-centered plan, if the participant's health circumstances necessitate a change, but in any event, the plan will be reviewed and updated at least annually. Entities or individuals that have responsibility for service plan development may not provide other direct demonstration services to the participant.

The State will establish minimum guidelines regarding the person-centered service plan, the process for the development of the plan, and the monitoring of its implementation. These expectations must be reflected in any contract or provider agreement.

The required subject areas are:
 The individuals who develop the person-centered service plan (and their requisite qualifications);
 The individuals who are expected to participate in the plan development process;
 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);
 Types of assessments that are conducted as a part of the service plan development process;
 How participants are informed of the services available to them;
 How the process ensures that the service plan addresses the participants desired outcomes, needs and preferences;
 The plans' responsibilities for implementing and monitoring the plan of care.

<insert information>

Cost Sharing

1. Co-payments (if applicable).

<check the appropriate box>

□ Demonstration enrollees do not pay a co-payment for any services.

□ Demonstration enrollees pay a co-payment for the following services:

Demonstration Co-Pays

Services	Co-payment
<insert service>	<insert co-payment amounts>

No co-payment may be imposed on enrollees with respect to the following services and populations:

• Individuals under 21 years of age;

• Preventive Services

• Family Planning Services

• An individual who is an inpatient in a hospital, nursing facility, or other institution, and is required to spend all their income for costs of care, with the exception of a minimal amount of for personal needs;

• Pregnant women, and services furnished during the post-partum phase of maternity care;

• Emergency services;

• Any other service or services required to be exempt under the provisions of the Social Security Act, Title XIX and successors to it.

2. Monthly Premiums. < if applicable, please insert premium information based on FPL level>

□ Enrollees are not responsible for payment of a monthly premium

□ Enrollees are responsible for payment of a monthly premium dependent on their income level. <complete chart below>

Income Level	Monthly Premium
<if applicable, create a row for each FPL range that has a monthly premium>	<insert premium amount>

3. Cost Sharing Protections. In the event demonstration “enrollees” fail to pay premiums by the date on which they are due, the State will provide a reasonable grace period of no less than 30 days during which the enrollee may make the payment without termination from the program. During the grace period, the State will notify the enrollee of failure to make the required payment and may face termination from the program if the payment is not made. The State will give the individual the right to appeal any adverse actions for failure to pay premiums. In addition, before final disenrollment can occur, the State will perform a Medicaid eligibility determination to ensure that the participant is not eligible for the State plan. If the Medicaid eligibility determination finds that the demonstration enrollee is ineligible for Medicaid, the State will disenroll the participant. The individual may reenroll in the Demonstration as soon as the individual is able to pay the required premium, subject to enrollment limitations.

Service Delivery Model

4. Service Delivery.

□ Managed Care

< insert service delivery model description, including plan types, risk arrangement, intended contractual incentives, innovative payment models (including incentives), beneficiary protections and outreach strategies, network accessibility and adequacy and readiness strategy>

□ Managed Care including opportunities for Self Direction

<insert service delivery model description, including plan types, risk arrangement, intended contractual incentives, , innovative payment models (including incentives) , beneficiary protections and outreach strategies, network accessibility and adequacy and readiness strategy and self direction structures>

□ Fee for Service

<insert service delivery model description, including any bundled payment arrangements, pay for performance, FFS care management models/non-risk>

□ Fee for Service including opportunities for Self Direction

<insert service delivery model description, including any bundled payment arrangements, pay for performance, FFS care management models/non-risk, self-direction structures>

□ Other Service Delivery Strategies Employed in the Demonstration

<insert service delivery model description, including any bundled payment arrangements, pay for performance, FFS care management models/non-risk, self-direction structures>

□ Coordination with Medicare (as applicable)

<To the extent that the demonstration provides services to individuals dually eligible for Medicare and Medicaid, please describe the strategies the State will use to coordinate and/or align Medicaid and Medicare services for these individuals. >

Quality

<insert description of the quality improvement strategies to be employed in the operation of the demonstration. For demonstrations including HCBS, please describe strategies to ensure health and welfare of individuals to be served and other requirements to ensure quality of care and systems of oversight, including any measures that will be utilized >

Approach to Budget Neutrality

Demonstrations must be budget-neutral. This means that the proposed demonstration cannot cost the Federal government more than it would absent the demonstration. In order to meet budget neutrality requirements, CMS and the State establish a budget ceiling based on five years of historic State specific expenditure data for each individual population the State is going to include in the demonstration. CMS is available to provide technical assistance to States in the development of their budget neutrality model.

<insert description of the State’s contemplated approach to budget neutrality to be employed in the operation of the demonstration>

Approach to Evaluation

<insert description of the State’s anticipated approach to evaluation; if the demonstration includes strategies to align Medicare and Medicaid services, describe whether or not Medicare data is included. >

Standard Terms and Conditions

To be negotiated with CMS

See Companion Sample STC Document for Terms and Conditions that may be appropriate for use in your demonstration (including parameters and requirements for managed care; consumer outreach and engagement; evaluation; budget neutrality; reporting and others).

Waiver List: Sections of the Statute waived by this Demonstration

CMS will assist State in determining which waivers are required

<End of application>

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