Subject: Application for 1915(c) HCBS Waiver: Draft GU.11.00.00
From: "Saved by Windows Internet Explorer 8"
Date: Thu, 30 May 2013 15:35:26 -0400

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.

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

1. Request Information (1 of 3)

The State of Guam 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).

Program
Title (optional - this
title will be used to locate this waiver in the finder):

Type of
Request: new

New to replace
waiver

Replacing Waiver
Number:

Migration Waiver - this is an existing approved waiver

Provide the information about the original waiver
being migrated

Base Waiver Number:

Amendment Number

(if
applicable):

Effective Date: (mm/dd/yy)

Draft
ID: GU.11.00.00

Type of Waiver (select only one):
Model Waiver
Regular Waiver

Proposed
Effective Date:
(mm/dd/yy)

1. Request Information (2 of 3)

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):

Hospital

Select applicable level of care

Hospital as defined in 42 CFR §440.10

If
applicable, specify whether the State additionally limits the waiver to
subcategories of the hospital level of care:

Character Count: out of 6000

Inpatient psychiatric facility for individuals
age 21 and under as provided in42 CFR §440.160

not selected

Nursing
Facility

Select applicable level of care

Nursing Facility As defined in 42 CFR §440.40
and 42 CFR §440.155

If
applicable, specify whether the State additionally limits the waiver to
subcategories of the nursing facility level of care:

Character Count:
out of 6000

Institution for Mental Disease for persons with
mental illnesses aged 65 and older as provided in 42 CFR §440.140

not selected

Intermediate Care Facility for the Mentally Retarded (ICF/MR)
(as defined in 42 CFR §440.150)

If
applicable, specify whether the State additionally limits the waiver to
subcategories of the ICF/MR level of care:

Character Count: out of 6000

1. Request Information (3 of 3)

Concurrent Operation with Other Programs.
This waiver operates concurrently with another
program (or programs) approved under the following authorities

Select one:

Not applicable

Applicable

Check the applicable authority or authorities:

Services furnished under
the provisions of §1915(a)(1)(a) of the Act and described in Appendix
I

Waiver(s) authorized under §1915(b) of the
Act.

Specify the
§1915(b) waiver program and indicate whether a §1915(b) waiver application has
been submitted or previously approved:

Character
Count: out of
6000

Specify the
§1915(b) authorities under which this program operates (check each that
applies):

§1915(b)(1) (mandated
enrollment to managed care)

§1915(b)(2) (central
broker)

§1915(b)(3) (employ cost
savings to furnish additional services)

§1915(b)(4) (selective
contracting/limit number of providers)

A program operated under §1932(a) of the Act.

Specify the nature
of the State Plan benefit and indicate whether the State Plan Amendment has
been submitted or previously approved:

Character
Count: out of
6000

A program authorized under §1915(i) of the Act.

A program authorized under §1915(j) of the Act.

A program authorized under §1115 of the Act.

Specify the
program:

Character
Count: out of 6000

Not applicable

not selected

2. Brief Waiver Description

Brief Waiver Description. In one page
or less, briefly describe the purpose of the waiver, including its
goals, objectives, organizational structure (e.g., the roles of state, local and
other entities), and service delivery methods.

Character
Count: out of 6000

3. Components of the Waiver Request

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

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

Participant Access and Eligibility.
Appendix B specifies the target group(s) of individuals who
are served in this waiver, the number of participants that the State expects
to serve during each year that the waiver is in effect, applicable Medicaid
eligibility and post-eligibility (if applicable) requirements, and procedures
for the evaluation and reevaluation of level of care.

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

Participant-Centered Service Planning and
Delivery. Appendix D specifies the procedures and
methods that the State uses to develop, implement and monitor the
participant-centered service plan (of care).

Participant-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):

Yes. This waiver provides participant
direction opportunities. Appendix E is
required.

No. This waiver does not provide
participant direction opportunities. Appendix E is not required.

not selected

Participant Rights. Appendix
F specifies how the State informs participants of their Medicaid Fair
Hearing rights and other procedures to address participant grievances and
complaints.

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

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

Financial Accountability.
Appendix I describes the methods by which the State makes
payments for waiver services, ensures the integrity of these payments, and
complies with applicable federal requirements concerning payments and federal
financial participation.

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

4. Waiver(s) Requested

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.

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):

Not Applicable

No

Yes

not selected

Statewideness. Indicate whether the
State requests a waiver of the statewideness requirements in §1902(a)(1) of
the Act (select one):

No

Yes

If yes, specify the waiver of statewideness that is
requested (check each that applies):

Geographic Limitation. A waiver of
statewideness is requested in order to furnish services under this waiver only
to individuals who reside in the following geographic areas or political
subdivisions of the State.

Specify the areas to which this waiver applies and, as
applicable, the phase-in schedule of the waiver by geographic
area:

Character
Count: out of 6000

Limited Implementation of Participant-Direction. A waiver of
statewideness is requested in order to make participant-direction of services as specified in
Appendix E
available
only to individuals who reside in the following geographic areas or political
subdivisions of the State. Participants who reside in these areas may elect to
direct their services as provided by the State or receive comparable services
through the service delivery methods that are in effect elsewhere in the
State.

Specify the areas of the State affected by this waiver
and, as applicable, the phase-in schedule of the waiver by geographic
area:

Character
Count: out of 6000

5. Assurances

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

Health & Welfare: The State assures
that necessary safeguards have been taken to protect the health and welfare of
persons receiving services under this waiver. These safeguards include:

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

Assurance that the standards of any State licensure or
certification requirements specified in Appendix C are met
for services or for individuals furnishing services that are provided under
the waiver. The State assures that these requirements are met on the date
that the services are furnished; and,

Assurance that all facilities subject to §1616(e) of
the Act where home and community-based waiver services are provided comply
with the applicable State standards for board and care facilities as
specified in Appendix C.

Financial Accountability. The State
assures financial accountability for funds expended for home and
community-based services and maintains and makes available to the Department
of Health and Human Services (including the Office of the Inspector General),
the Comptroller General, or other designees, appropriate financial records
documenting the cost of services provided under the waiver. Methods of
financial accountability are specified in Appendix I.

Evaluation of Need: The State assures
that it provides for an initial evaluation (and periodic reevaluations, at
least annually) of the need for a level of care specified for this waiver,
when there is a reasonable indication that an individual might need such
services in the near future (one month or less) but for the receipt of home
and community based services under this waiver. The procedures for evaluation
and reevaluation of level of care are specified in Appendix
B.

Choice of Alternatives: The State assures that when an
individual is determined to be likely to require the level of care specified
for this waiver and is in a target group specified in Appendix
B, the individual (or, legal representative, if applicable) is:

Informed of any feasible alternatives under the
waiver; and,

Given the choice of either institutional or home and
community based waiver services. Appendix B specifies the
procedures that the State employs to ensure that individuals are informed of
feasible alternatives under the waiver and given the choice of institutional
or home and community-based waiver services.

Average Per Capita Expenditures: The
State assures that, for any year that the waiver is in effect, the average per
capita expenditures under the waiver will not exceed 100 percent of the
average per capita expenditures that would have been made under the Medicaid
State plan for the level(s) of care specified for this waiver had the waiver
not been granted. Cost-neutrality is demonstrated in Appendix
J.

Actual Total Expenditures: The State
assures that the actual total expenditures for home and community-based waiver
and other Medicaid services and its claim for FFP in expenditures for the
services provided to individuals under the waiver will not, in any year of the
waiver period, exceed 100 percent of the amount that would be incurred in the
absence of the waiver by the State's Medicaid program for these individuals in
the institutional setting(s) specified for this waiver.

Institutionalization Absent Waiver: The
State assures that, absent the waiver, individuals served in the waiver would
receive the appropriate type of Medicaid-funded institutional care for the
level of care specified for this waiver.

Reporting: The State assures that
annually it will provide CMS with information concerning the impact of the
waiver on the type, amount and cost of services provided under the Medicaid
State plan and on the health and welfare of waiver participants. This
information will be consistent with a data collection plan designed by
CMS.

Habilitation Services. The State
assures that prevocational, educational, or supported employment services, or
a combination of these services, if provided as habilitation services under
the waiver are: (1) not otherwise available to the individual through a local
educational agency under the Individuals with Disabilities Education Act
(IDEA) or the Rehabilitation Act of 1973; and, (2) furnished as part of
expanded habilitation services.

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

6. Additional Requirements

Note: Item 6-I must be completed.

Service Plan. In accordance with 42 CFR
§441.301(b)(1)(i), a participant-centered service plan (of care) is developed
for each participant employing the procedures specified in Appendix
D. All waiver services are furnished pursuant to the service plan.
The service plan describes: (a) the waiver services that are furnished to the
participant, their projected frequency and the type of provider that furnishes
each service and (b) the other services (regardless of funding source,
including State plan services) and informal supports that complement waiver
services in meeting the needs of the participant. The service plan is subject
to the approval of the Medicaid agency. Federal financial participation (FFP)
is not claimed for waiver services furnished prior to the development of the
service plan or for services that are not included in the service plan.

Inpatients. In accordance with 42 CFR
§441.301(b)(1) (ii), waiver services are not furnished to individuals who are
in-patients of a hospital, nursing facility or ICF/MR.

Room and Board. In accordance with 42
CFR §441.310(a)(2), FFP is not claimed for the cost of room and board except
when: (a) provided as part of respite services in a facility approved by the
State that is not a private residence or (b) claimed as a portion of the rent
and food that may be reasonably attributed to an unrelated caregiver who
resides in the same household as the participant, as provided in
Appendix I.

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

Free Choice of Provider. In accordance
with 42 CFR §431.151, a participant may select any willing and qualified
provider to furnish waiver services included in the service plan unless the
State has received approval to limit the number of providers under the
provisions of §1915(b) or another provision of the Act.

FFP Limitation. In accordance with 42
CFR §433 Subpart D, FFP is not claimed for services when another third-party
(e.g., another third party health insurer or other federal or state program)
is legally liable and responsible for the provision and payment of the
service. FFP also may not be claimed for services that are available without
charge, or as free care to the community. Services will not be considered to
be without charge, or free care, when (1) the provider establishes a fee
schedule for each service available and (2) collects insurance information
from all those served (Medicaid, and non-Medicaid), and bills other legally
liable third party insurers. Alternatively, if a provider certifies that a
particular legally liable third party insurer does not pay for the service(s),
the provider may not generate further bills for that insurer for that annual
period.

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

Quality Improvement. The State operates
a formal, comprehensive system to ensure that the waiver meets the assurances
and other requirements contained in this application. Through an ongoing
process of discovery, remediation and improvement, the State assures the
health and welfare of participants by monitoring: (a) level of care
determinations; (b) individual plans and services delivery; (c) provider
qualifications; (d) participant health and welfare; (e) financial oversight
and (f) administrative oversight of the waiver. The State further assures that
all problems identified through its discovery processes are addressed in an
appropriate and timely manner, consistent with the severity and nature of the
problem. During the period that the waiver is in effect, the State will
implement the Quality Improvement Strategy specified in Appendix
H.

Public Input. Describe how the State secures public input into the
development of the waiver:

Character
Count: out of 6000

Notice to Tribal Governments. The State
assures that it has notified in writing all federally-recognized Tribal
Governments that maintain a primary office and/or majority population within
the State of the State's intent to submit a Medicaid waiver request or renewal
request to CMS at least 60 days before the anticipated submission date is
provided by Presidential Executive Order 13175 of November 6, 2000. Evidence
of the applicable notice is available through the Medicaid Agency.

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

7. Contact Person(s)

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

Last Name:

First Name:

Title:

Agency:

Address:

Address 2:

City:

State:

Guam

Zip:

Phone:

Ext: TTY

Fax:

E-mail:

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

Last
Name:

First
Name:

Title:

Agency:

Address:

Address 2:

City:

State:

Guam

Zip:

Phone:

Ext: TTY

Fax:

E-mail:

8. Authorizing Signature

This document, together with Appendices A
through J, constitutes the State's request for a waiver under §1915(c) of the
Social Security Act. The State assures that all materials referenced in this
waiver application (including standards, licensure and certification
requirements) are readily available in print or
electronic form upon request to CMS through the Medicaid agency or, if
applicable, from the operating agency specified in Appendix A. Any proposed
changes to the waiver will be submitted by the Medicaid agency to CMS in the
form of waiver amendments.

Upon approval by CMS, the waiver application
serves as the State's authority to provide home and community-based waiver
services to the specified target groups. The State attests that it will abide by
all provisions of the approved waiver and will continuously operate the waiver
in accordance with the assurances specified in Section 5 and the additional
requirements specified in Section 6 of the request.

Signature:

State Medicaid Director or Designee

Submission
Date:

Last
Name:

First
Name:

Title:

Agency:

Address:

Address
2:

City:

State:

Guam

Zip:

Phone:

Fax:

E-mail:

Attachment #1: Transition Plan

Specify the transition plan for the waiver:

Character Count: out of 12000

Additional Needed Information (Optional)

Provide additional needed information for the waiver
(optional):

Character Count: out of 60000

Appendix A: Waiver Administration and Operation

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

The waiver is operated by the State
Medicaid agency.

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

The Medical Assistance Unit.

Specify the unit name:
(Do not complete item A-2)

Another division/unit within the State
Medicaid agency that is separate from the Medical Assistance
Unit.

Specify the division/unit name. This includes
administrations/divisions under the umbrella agency that has been identified
as the Single State Medicaid Agency.
(Complete item A-2-a).

not selected

The waiver is operated by a separate agency
of the State that is not a division/unit of the Medicaid agency.

Specify the division/unit name:

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).

not selected

Appendix A: Waiver Administration and Operation

Oversight of
Performance.

Medicaid Director Oversight of Performance
When the Waiver is Operated by another Division/Unit within the State
Medicaid Agency. When the waiver
is operated by another division/administration within the umbrella agency
designated as the Single State Medicaid Agency. Specify (a) the functions
performed by that division/administration (i.e., the Developmental
Disabilities Administration within the Single State Medicaid Agency), (b)
the document utilized to outline the roles and responsibilities related to
waiver operation, and (c) the methods that are employed by the designated
State Medicaid Director (in some instances, the head of umbrella agency) in
the oversight of these activities:
Complete
Appendix A-1 before completing this section.

Character
Count: out of
12000

Medicaid Agency Oversight of Operating
Agency Performance. When the waiver is
not operated by the Medicaid agency, specify the functions that are
expressly delegated through a memorandum of understanding (MOU) or other
written document, and indicate the frequency of review and update for that
document. Specify the methods that the Medicaid agency uses to ensure that
the operating agency performs its assigned waiver operational and
administrative functions in accordance with waiver requirements. Also
specify the frequency of Medicaid agency assessment of operating agency
performance:
Complete Appendix A-1 before completing this
section.

Character
Count: out of
12000

Appendix A: Waiver Administration and Operation

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):

Yes. Contracted entities perform waiver
operational and administrative functions on behalf of the Medicaid agency
and/or operating agency (if applicable).

Specify the types
of contracted entities and briefly describe the functions that they
perform. Complete Items A-5 and A-6.:

Character
Count: out of
6000

No. Contracted entities do not perform
waiver operational and administrative functions on behalf of the Medicaid
agency and/or the operating agency (if applicable).

not selected

Appendix A: Waiver Administration and Operation

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):

not selected

Not applicable

Applicable - Local/regional non-state
agencies perform waiver operational and administrative functions.

Check each that applies:

Local/Regional non-state public agencies perform waiver
operational and administrative functions at the local or regional level. There
is an interagency agreement or memorandum of
understanding between the State and these agencies that sets forth
responsibilities and performance requirements for these agencies that is
available through the Medicaid agency.

Specify the nature of these agencies and complete
items A-5 and A-6:

Character
Count: out of 6000

Local/Regional non-governmental non-state
entities
conduct waiver operational and administrative functions at the local or
regional level. There is a contract between the Medicaid agency and/or the
operating agency (when authorized by the Medicaid agency) and each
local/regional non-state entity that sets forth the responsibilities and
performance requirements of the local/regional entity. The contract(s) under which private
entities conduct waiver operational functions are available to CMS upon
request through the Medicaid agency or the operating agency (if
applicable).

Specify the nature of these entities and complete
items A-5 and A-6:

Character
Count: out of 6000

Not applicable - Local/regional
non-state agencies do not perform waiver operational and administrative
functions.

Appendix A: Waiver Administration and Operation

Responsibility for Assessment of Performance of
Contracted and/or Local/Regional Non-State Entities. Specify the state agency or agencies responsible for
assessing the performance of contracted and/or local/regional non-state
entities in conducting waiver operational and administrative
functions:
Please complete Appendix A-3 and A-4 before completing this
section

Character
Count: out of 6000

Appendix A: Waiver Administration and Operation

Assessment Methods and Frequency. Describe the methods that are used to assess the
performance of contracted and/or local/regional non-state entities to ensure
that they perform assigned waiver operational and administrative functions in
accordance with waiver requirements. Also specify how frequently the
performance of contracted and/or local/regional non-state entities is
assessed:
Please complete Appendix A-3 and A-4 before completing this
section

Character
Count: out of 6000

Appendix A: Waiver Administration and Operation

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.

Function

Medicaid
Agency

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.

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.

Performance Measures

For each performance
measure/indicator the State will use to assess compliance with the statutory
assurance complete the following. Where possible, include
numerator/denominator. Each performance measure must be specific to this
waiver (i.e., data presented must be waiver specific).

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.

If applicable, in the textbox below provide any necessary
additional information on the strategies employed by the State to
discover/identify problems/issues within the waiver program, including
frequency and parties responsible.

Character
Count: out of 6000

Methods for Remediation/Fixing
Individual Problems

Describe the State’s method for addressing individual
problems as they are discovered. Include information regarding responsible
parties and GENERAL methods for problem correction. In addition, provide
information on the methods used by the State to document these items.

Character Count: out of 6000

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):

State Medicaid
Agency

Weekly

Operating
Agency

Monthly

Sub-State
Entity

Quarterly

Other

Specify:

Annually

Continuously and
Ongoing

Other

Specify:

Timelines

When the State does not have all elements of the Quality
Improvement Strategy in place, provide timelines to design methods for
discovery and remediation related to the assurance of Financial Accountability
that are currently non-operational.

No

Yes

not selected

Please provide a
detailed strategy for assuring Administrative Authority, the specific timeline
for implementing identified strategies, and the parties responsible for its
operation.

Character
Count: out of 6000

Appendix B: Participant Access and Eligibility

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

Target Group(s). Under the waiver of
Section 1902(a)(10)(B) of the Act, the State limits waiver services to a group
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
waiver target group, check each of the subgroups in the selected target group
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 or Disabled, or Both -
General

Aged

Disabled (Physical)

Disabled (Other)

Aged or Disabled, or Both - Specific
Recognized Subgroups

Brain Injury

HIV/AIDS

Medically Fragile

Technology Dependent

Mental Retardation or Developmental
Disability, or Both

Autism

Developmental Disability

Mental Retardation

Mental Illness

Mental Illness

Serious Emotional Disturbance

not
selected

Additional Criteria. The State further
specifies its target group(s) as follows:

Character
Count: out of 12000

Transition of Individuals Affected by Maximum Age Limitation.
When there
is a maximum age limit that applies to individuals who may be served in the
waiver, describe the transition planning procedures that are undertaken on
behalf of participants affected by the age limit (select
one):

Not applicable. There is no
maximum age limit

The following transition planning
procedures are employed for participants who will reach the waiver's
maximum age limit.

Specify:

Character
Count: out of
12000

Appendix B: Participant Access and Eligibility

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

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:

No Cost Limit. The State does not apply an individual cost limit. Do
not complete Item B-2-b or item B-2-c.

Cost Limit in Excess of Institutional
Costs. 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)

A level higher than 100% of the
institutional average.

Specify the percentage:

Other

Specify:

Character
Count: out of 6000

not selected

Institutional Cost Limit. 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.

Cost Limit Lower Than Institutional
Costs. 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.

Specify the basis
of the limit, including evidence that the limit is sufficient to assure the
health and welfare of waiver participants. Complete Items B-2-b and
B-2-c.

Character
Count: out of 6000

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

The following dollar amount:

Specify dollar
amount:

The dollar amount (select one)

Is adjusted each year that the waiver is
in effect by applying the following formula:

Specify the formula:

Character
Count: out of 6000

May be adjusted during the period the
waiver is in effect. The State will submit a waiver amendment to CMS to adjust
the dollar amount.

not
selected

The following percentage that is less
than 100% of the institutional average:

Specify percent:

Other:

Specify:

Character
Count: out of
6000

not selected

not selected

Appendix B: Participant Access and Eligibility

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

Please complete Appendix B-2-a before completing this
section.

Method of Implementation of the Individual
Cost Limit. When an individual cost limit is specified in Item B-2-a,
specify the procedures that are followed to determine in advance of waiver
entrance that the individual's health and welfare can be assured within the
cost limit:

Character
Count: out of 12000

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):

The participant is referred
to another waiver that can accommodate the individual's needs.

Additional services in excess of the individual cost limit
may be authorized.

Specify the
procedures for authorizing additional services, including the amount that may
be authorized:

Character
Count: out of
12000

Other safeguard(s)

Specify:

Character
Count: out of
12000

Appendix B: Participant Access and Eligibility

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

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

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):

The State does not limit the number of
participants that it serves at any point in time during a waiver
year.

The State limits the number of participants
that it serves at any point in time during a waiver
year.

The
limit that applies to each year of the waiver period is specified in the
following table:

Table: B-3-b

Waiver Year

Maximum Number of Participants Served At Any Point During
the Year

Year 1

Year 2

Year 3

Appendix B: Participant Access and Eligibility

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

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):

Not applicable. The state does not reserve
capacity.

The State reserves capacity for the
following purpose(s).

Appendix B: Participant Access and Eligibility

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

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):

The waiver is not subject to a
phase-in or a phase-out schedule.

The waiver is subject to a
phase-in or phase-out schedule that is included in Attachment #1 to
Appendix B-3. This schedule constitutes an intra-year limitation on the
number of participants who are served in the
waiver.

Allocation of Waiver Capacity.

Select one:

Waiver capacity is allocated/managed on
a statewide basis.

Waiver capacity is allocated to
local/regional non-state entities.

Specify: (a) the entities to which waiver capacity is
allocated; (b) the methodology that is used to allocate capacity and how often
the methodology is reevaluated; and, (c) policies for the reallocation of
unused capacity among local/regional non-state entities:

Character
Count: out of
12000

Selection of Entrants to the Waiver.
Specify the policies that apply to the selection of
individuals for entrance to the waiver:

Character
Count: out of 12000

Appendix B: Participant Access and Eligibility

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

Please complete Appendix B-3-d before
completing this section.

Appendix B: Participant Access and Eligibility

B-4: Eligibility Groups Served in the Waiver

Note: Complete this section prior to starting B-5:
Post-Eligibility Treatment of Income

State Classification. The State is
a (select one):

§1634 State

SSI Criteria State

209(b) State

not selected

Miller Trust
State.

Indicate whether the State is a Miller Trust State
(select one):

No

Yes

Unknown

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)

Low income families with
children as provided in §1931 of the Act

SSI
recipients

Aged, blind or disabled in 209(b) states who are eligible
under 42 CFR §435.121

Optional State supplement
recipients

Optional categorically needy aged and/or disabled individuals
who have income at:

Select one:

100% of the Federal poverty level
(FPL)

% of FPL, which is lower than 100% of
FPL.

Specify percentage:

not selected

Working individuals with
disabilities who buy into Medicaid (BBA working disabled group as provided in
§1902(a)(10)(A)(ii)(XIII)) of the Act)

Working individuals with
disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in
§1902(a)(10)(A)(ii)(XV) of the Act)

Working individuals
with disabilities who buy into Medicaid (TWWIIA Medical Improvement Coverage
Group as provided in §1902(a)(10)(A)(ii)(XVI) of the Act)

Disabled individuals
age 18 or younger who would require an institutional level of care (TEFRA 134
eligibility group as provided in §1902(e)(3) of the Act)

Medically
needy

Medically needy in 209(b)
States (42 CFR §435.330)

Medically needy in 1634
States and SSI Criteria States (42 CFR §435.320, §435.322 and
§435.324)

Other specified groups (include only statutory/regulatory
reference to reflect the additional groups in the State plan that may receive
services under this waiver)

Specify:

Character
Count: 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

No. 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.

Yes. The State furnishes waiver services to individuals
in the special home and community-based waiver group under 42 CFR
§435.217.

not selected

Select one and complete Appendix
B-5.

All individuals in the special home and
community-based waiver group under 42 CFR §435.217

Only the following groups of individuals
in the special home and community-based waiver group under 42 CFR
§435.217

not selected

Check each that applies:

A special income level equal to:

Select one:

300% of the SSI Federal Benefit Rate
(FBR)

A percentage of FBR, which is lower
than 300% (42 CFR §435.236)

Specify percentage:

A dollar amount which is lower than
300%.

Specify dollar
amount:

not selected

Aged, blind and disabled
individuals who meet requirements that are more restrictive than the SSI
program (42 CFR §435.121)

Medically needy without
spenddown in States which also provide Medicaid to recipients of SSI (42 CFR
§435.320, §435.322 and §435.324)

Medically needy without
spend down in 209(b) States (42 CFR §435.330)

Aged and disabled individuals
who have income at:

Select one:

100% of FPL

% of FPL, which is lower than
100%.

Specify percentage amount:

not selected

Other specified groups (include only statutory/regulatory
reference to reflect the additional groups in the State plan that may receive
services under this waiver)

Specify:

Character
Count: out of 6000

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (1 of 4)

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. A State that uses spousal impoverishment rules under §1924 of the Act to
determine the eligibility of individuals with a community spouse may elect to
use spousal post-eligibility rules under §1924 of the Act to protect a personal
needs allowance for a participant with a community spouse.

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 (select one):

Please complete Appendix B-4 before completing
this section

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (2 of 4)

Regular Post-Eligibility Treatment of Income:
SSI State.

Please complete Appendix B-5a before completing
this section

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (3 of 4)

Regular Post-Eligibility Treatment of Income:
209(B) State.

Please complete Appendix B-5a before completing
this section

Appendix B: Participant Access and Eligibility

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

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).

Please complete Appendix B-5a before completing this
section

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.

Reasonable Indication of Need for
Services. In order for an individual to be determined to need waiver
services, an individual must require: (a) the provision of at least one waiver
service, as documented in the service plan, and (b) the provision of
waiver services at least monthly or, if the need for services is less than
monthly, the participant requires regular monthly monitoring which must be
documented in the service plan. Specify the State's policies concerning the
reasonable indication of the need for services:

Minimum number of services.

The minimum number of waiver services (one or more) that
an individual must require in order to be determined to need waiver services
is:

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

The provision of waiver services at
least monthly

Monthly monitoring of the individual
when services are furnished on a less than monthly basis

If the State also requires a minimum frequency for
the provision of waiver services other than monthly (e.g., quarterly),
specify the frequency:

Character
Count: out of
4000

not selected

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

Directly by the Medicaid agency

By the operating agency specified in
Appendix A

By an entity under contract with the
Medicaid agency.

Specify the
entity:

Character
Count: out of
4000

Other

Specify:

Character
Count: out of
4000

not selected

Qualifications of Individuals Performing
Initial Evaluation: Per 42 CFR
§441.303(c)(1), specify the educational/professional qualifications of
individuals who perform the initial evaluation of level of care for waiver
applicants:

Character
Count: out of
6000

Level of Care Criteria. Fully specify the level of care criteria that are used to
evaluate and reevaluate whether an individual needs services through the
waiver and that serve as the basis of the State's level of care
instrument/tool. Specify the level of care instrument/tool that is employed.
State laws, regulations, and policies concerning level of care criteria and
the level of care instrument/tool are available to CMS upon request through
the Medicaid agency or the operating agency (if applicable), including the
instrument/tool utilized.

Character
Count: out of 12000

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):

The same instrument is used in
determining the level of care for the waiver and for institutional care under
the State Plan.

A different instrument is used to
determine the level of care for the waiver than for institutional care under
the State plan.

Describe how and
why this instrument differs from the form used to evaluate institutional level
of care and explain how the outcome of the determination is reliable, valid,
and fully comparable.

Character
Count: out of
12000

not selected

Process for Level of Care
Evaluation/Reevaluation: Per 42 CFR §441.303(c)(1),
describe the process for evaluating waiver applicants for their need for the
level of care under the waiver. If the reevaluation process differs from the
evaluation process, describe the differences:

Character Count: out of 12000

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):

Every three months

Every six months

Every twelve months

Other schedule

Specify the
other schedule:

Character
Count: out of
4000

not selected

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

The qualifications of individuals
who perform reevaluations are the same as individuals who perform initial
evaluations.

The qualifications are
different.

Specify
the qualifications:

Character
Count: out of
6000

not selected

Procedures to Ensure Timely
Reevaluations. Per 42 CFR §441.303(c)(4), specify the procedures that the
State employs to ensure timely reevaluations of level of care (specify):

Character Count: out of 6000

Maintenance of Evaluation/Reevaluation
Records. Per 42 CFR §441.303(c)(3), the State assures that written
and/or electronically retrievable documentation of all evaluations and
reevaluations are maintained for a minimum period of 3 years as required in 45
CFR §92.42. Specify the location(s) where records of evaluations and
reevaluations of level of care are maintained:

Character
Count: 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.

Methods for Discovery: Level of
Care Assurance/Sub-assurances

Sub-Assurances:

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/indicator the State will use to assess compliance
with the statutory assurance complete the following. Where possible,
include numerator/denominator. Each performance measure must be specific
to this waiver (i.e., data presented must be waiver specific).

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

Sub-assurance: The
levels of care of enrolled participants are reevaluated at least annually
or as specified in the approved waiver.

Performance Measures

For
each performance measure/indicator the State will use to assess compliance
with the statutory assurance complete the following. Where possible,
include numerator/denominator. Each performance measure must be specific
to this waiver (i.e., data presented must be waiver specific).

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

Sub-assurance: The
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/indicator the State will use to assess compliance
with the statutory assurance complete the following. Where possible,
include numerator/denominator. Each performance measure must be specific
to this waiver (i.e., data presented must be waiver specific).

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.

If applicable, in the
textbox below provide any necessary additional information on the strategies
employed by the State to discover/identify problems/issues within the waiver
program, including frequency and parties responsible.

Character
Count: out of 6000

Methods for Remediation/Fixing
Individual Problems

Describe the State’s method for addressing individual
problems as they are discovered. Include information regarding responsible
parties and GENERAL methods for problem correction. In addition, provide
information on the methods used by the State to document these items.

Character
Count: out of 6000

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):

State Medicaid
Agency

Weekly

Operating
Agency

Monthly

Sub-State
Entity

Quarterly

Other

Specify:

Annually

Continuously and
Ongoing

Other

Specify:

Timelines

When the State does not have all elements of the Quality
Improvement Strategy in place, provide timelines to design methods for
discovery and remediation related to the assurance of Financial Accountability
that are currently non-operational.

No

Yes

not selected

Please provide a
detailed strategy for assuring Administrative Authority, the specific timeline
for implementing identified strategies, and the parties responsible for its
operation.

Character
Count: 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:

informed of any feasible alternatives under the waiver; and

given the choice of either institutional or home and community-based
services.

Procedures. Specify the State's
procedures for informing eligible individuals (or their legal representatives)
of the feasible alternatives available under the waiver and allowing these
individuals to choose either institutional or waiver services. Identify the
form(s) that are employed to document freedom of choice. The form or forms are
available to CMS upon request through the Medicaid agency or the operating
agency (if applicable).

Character Count: out of 12000

Maintenance of Forms. Per 45 CFR §92.42, written copies or electronically
retrievable facsimiles of Freedom of Choice forms are maintained for a minimum
of three years. Specify the locations where copies of these forms are
maintained.

Character Count: 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. Specify the methods that the State uses to provide meaningful
access to the waiver by Limited English Proficient persons in accordance with
the 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):

Character
Count: out of 12000

Appendix C: Participant Services

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

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
Type

Service

Appendix C: Participant Services

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

Provision of Case Management Services to
Waiver Participants. Indicate how case management is furnished to
waiver participants (select one):

not selected

Not applicable - Case management is not furnished as a distinct activity
to waiver participants.

Applicable -
Case management is furnished as a distinct activity to waiver
participants.

Check each that applies:

As a waiver service
defined in Appendix C-3. Do not
complete item C-1-c.

As a Medicaid State plan
service under §1915(i) of the Act (HCBS as a State Plan
Option). Complete item
C-1-c.

As a Medicaid State plan
service under §1915(g)(1) of the Act (Targeted Case
Management). Complete item
C-1-c.

As an administrative
activity. Complete item C-1-c.
NOTE: Pursuant to CMS-2237-IFC this selection is no
longer available for 1915(c) waivers.

Not applicable - Case management is not furnished as a
distinct activity to waiver participants. Do not complete item C-1-c.

None of the above apply - Case management is furnished as a waiver service (Do not
complete item C-1-c).

Delivery of Case Management Services. Specify the entity or entities that conduct case management
functions on behalf of waiver participants:

Character Count: out of 4000

Appendix C: Participant Services

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

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 waiver services (select
one):

No. Criminal history and/or background
investigations are not required.

Yes. Criminal history and/or background
investigations are required.

Specify: (a) the types of positions (e.g., personal
assistants, attendants) for which such investigations must be conducted; (b)
the scope of such investigations (e.g., state, national); and, (c) the process
for ensuring that mandatory investigations have been conducted. State laws,
regulations and policies referenced in this description are available to CMS
upon request through the Medicaid or the operating agency (if
applicable):

Character
Count: out of 12000

Abuse Registry Screening. Specify whether the State requires the screening of
individuals who provide waiver services through a State-maintained abuse
registry (select one):

No. The State does not conduct abuse
registry screening.

Yes. The State maintains an abuse registry
and requires the screening of individuals through this
registry.

Specify: (a) the
entity (entities) responsible for maintaining the abuse registry; (b) the
types of positions for which abuse registry screenings must be conducted; and,
(c) the process for ensuring that mandatory screenings have been conducted.
State laws, regulations and policies referenced in this description are
available to CMS upon request through the Medicaid agency or the operating
agency (if applicable):

Character
Count: out of
12000

Appendix C: Participant Services

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

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

No. Home and community-based services under
this waiver are not provided in facilities subject to §1616(e) of the
Act.

Yes. Home and community-based services are
provided in facilities subject to §1616(e) of the Act. The standards
that apply to each type of facility where waiver services are provided
are available to CMS upon request through the Medicaid agency or the
operating agency (if applicable).

Appendix C: Participant Services

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

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:

No. The State does not make payment to
legally responsible individuals for furnishing personal care or similar
services.

Yes. The State makes payment to legally
responsible individuals for furnishing personal care or similar services when
they are qualified to provide the services.

Specify: (a) the legally responsible individuals who may be
paid to furnish such services and the services they may provide; (b) State
policies that specify the circumstances when payment may be authorized for the
provision of extraordinary care by a legally
responsible individual and how the State ensures that the provision of
services by a legally responsible individual is in the best interest of the
participant; and, (c) the controls that are employed to ensure that payments
are made only for services rendered. Also, specify
in Appendix C-1/C-3 the personal care or similar services for which payment
may be made to legally responsible individuals under the State policies
specified here.

Character
Count: out of
12000

not selected

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:

The State does not make payment to
relatives/legal guardians for furnishing waiver services.

The State makes payment to relatives/legal
guardians under specific circumstances and only when the relative/guardian is
qualified to furnish services.

Specify the specific circumstances under which payment is
made, the types of relatives/legal guardians to whom payment may be made, and
the services for which payment may be made. Specify the controls that are
employed to ensure that payments are made only for services
rendered. Also, specify in Appendix C-1/C-3 each waiver service
for which payment may be made to relatives/legal guardians.

Character
Count: out of 12000

Relatives/legal guardians may be paid for
providing waiver services whenever the relative/legal guardian is qualified to
provide services as specified in Appendix C-1/C-3.

Specify the
controls that are employed to ensure that payments are made only for services
rendered.

Character
Count: out of
12000

Other policy.

Specify:

Character
Count: out of
12000

not selected

Open Enrollment of Providers. Specify the processes that are employed to assure that all
willing and qualified providers have the opportunity to enroll as waiver
service providers as provided in 42 CFR §431.51:

Character Count: 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.

Methods for Discovery: Qualified
Providers

Sub-Assurances:

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/indicator the State will use to assess compliance with the
statutory assurance complete the following. Where possible, include
numerator/denominator. Each performance measure must be specific to this
waiver (i.e., data presented must be waiver specific).

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

Sub-Assurance: The
State monitors non-licensed/non-certified providers to assure adherence to
waiver requirements.

For each performance
measure/indicator the State will use to assess compliance with the
statutory assurance complete the following. Where possible, include
numerator/denominator. Each performance measure must be specific to this
waiver (i.e., data presented must be waiver specific).

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

Sub-Assurance: The
State 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/indicator the State will use to assess compliance with the
statutory assurance complete the following. Where possible, include
numerator/denominator. Each performance measure must be specific to this
waiver (i.e., data presented must be waiver specific).

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.

If applicable, in the textbox below provide any necessary
additional information on the strategies employed by the State to
discover/identify problems/issues within the waiver program, including
frequency and parties responsible.

Character
Count: out of 6000

Methods for Remediation/Fixing
Individual Problems

Describe the State’s method for addressing individual
problems as they are discovered. Include information regarding responsible
parties and GENERAL methods for problem correction. In addition, provide
information on the methods used by the State to document these items.

Character Count: out of 6000

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):

State Medicaid
Agency

Weekly

Operating
Agency

Monthly

Sub-State
Entity

Quarterly

Other

Specify:

Annually

Continuously and
Ongoing

Other

Specify:

Timelines

When the State does not have all elements of the Quality
Improvement Strategy in place, provide timelines to design methods for
discovery and remediation related to the assurance of Financial Accountability
that are currently non-operational.

No

Yes

not selected

Please provide a
detailed strategy for assuring Administrative Authority, the specific timeline
for implementing identified strategies, and the parties responsible for its
operation.

Character
Count: 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

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).

not selected

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

Applicable - 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)

Limit(s) on Set(s) of
Services.
There is a limit on the maximum dollar amount of waiver services that is
authorized for one or more sets of services offered under the
waiver.

Furnish the
information specified above.

Character
Count: out of 24000

Prospective Individual Budget Amount. There is a limit on the
maximum dollar amount of waiver services authorized for each specific
participant.

Furnish the
information specified above.

Character
Count: out of 24000

Budget Limits by Level of
Support.
Based on an assessment process and/or other factors, participants are assigned
to funding levels that are limits on the maximum dollar amount of waiver
services.

Furnish the
information specified above.

Character
Count: out of 24000

Other Type of
Limit. The
State employs another type of limit.

Describe the limit
and furnish the information specified above.

Character
Count: out of 24000

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

Appendix D: Participant-Centered Planning and Service
Delivery

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

State Participant-Centered Service Plan Title:

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):

Registered nurse, licensed
to practice in the State

Licensed practical or
vocational nurse, acting within the scope of practice under State
law

Licensed physician (M.D. or D.O)

Case Manager (qualifications
specified in Appendix C-1/C-3)

Case
Manager (qualifications not specified in Appendix
C-1/C-3).

Specify
qualifications:

Character
Count: out of
6000

Social Worker.

Specify
qualifications:

Character
Count: out of
6000

Other

Specify the
individuals and their qualifications:

Character
Count: out of
6000

Appendix D: Participant-Centered Planning and Service
Delivery

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

Service Plan Development Safeguards.
Select one:

Entities and/or individuals that have
responsibility for service plan development may not provide other direct
waiver services to the participant.

Entities and/or individuals that have
responsibility for service plan development may provide other direct
waiver services to the participant.

The State has
established the following safeguards to ensure that service plan development
is conducted in the best interests of the participant.
Specify:

Character
Count: out of 6000

Appendix D: Participant-Centered Planning and Service
Delivery

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

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

Character
Count: out of 12000

Appendix D: Participant-Centered Planning and Service
Delivery

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

Service Plan Development Process.
In four pages or less, describe the process that is used to
develop the participant-centered service plan, including: (a) who develops the
plan, who participates in the process, and the timing of the plan; (b) the
types of assessments that are conducted to support the service plan
development process, including securing information about participant needs,
preferences and goals, and health status; (c) how the participant is informed
of the services that are available under the waiver; (d) how the plan
development process ensures that the service plan addresses participant goals,
needs (including health care needs), and preferences; (e) how waiver and other
services are coordinated; (f) how the plan development process provides for
the assignment of responsibilities to implement and monitor the plan; and, (g)
how and when the plan is updated, including when the participant's needs
change. State laws, regulations, and policies cited that affect the service
plan development process are available to CMS upon request through the
Medicaid agency or the operating agency (if applicable):

Character Count: out of 24000

Appendix D: Participant-Centered Planning and Service
Delivery

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

Risk Assessment and Mitigation.
Specify how potential risks to the participant are assessed
during the service plan development process and how strategies to mitigate
risk are incorporated into the service plan, subject to participant needs and
preferences. In addition, describe how the service plan development process
addresses backup plans and the arrangements that are used for
backup.

Character Count: out of 12000

Appendix D: Participant-Centered Planning and Service
Delivery

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

Informed Choice of Providers. Describe how participants are assisted in obtaining
information about and selecting from among qualified providers of the waiver
services in the service plan.

Character
Count: out of 6000

Appendix D: Participant-Centered Planning and Service
Delivery

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

Process for Making Service Plan Subject to the
Approval of the Medicaid Agency. Describe the process by which the service plan is made
subject to the approval of the Medicaid agency in accordance with 42 CFR
§441.301(b)(1)(i):

Character
Count: out of 6000

Appendix D: Participant-Centered Planning and Service
Delivery

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

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. Specify the minimum schedule for the review and update of
the service plan:

Every three months or more frequently when
necessary

Every six months or more frequently when
necessary

Every twelve months or more frequently when
necessary

Other schedule

Specify the other
schedule:

Character
Count: out of 6000

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):

Medicaid
agency

Operating
agency

Case
manager

Other

Specify:

Character
Count: out of
4000

Appendix D: Participant-Centered Planning and Service
Delivery

D-2: Service Plan Implementation and Monitoring

Service Plan Implementation and
Monitoring. Specify: (a) the entity (entities) responsible for
monitoring the implementation of the service plan and participant health and
welfare; (b) the monitoring and follow-up method(s) that are used; and, (c)
the frequency with which monitoring is performed.

Character Count: out of 24000

Monitoring Safeguards. Select
one:

Entities and/or individuals that have
responsibility to monitor service plan implementation and participant
health and welfare may not provide other direct waiver services to the
participant.

Entities and/or individuals that have
responsibility to monitor service plan implementation and participant
health and welfare may provide other direct waiver services to the
participant

The State has
established the following safeguards to ensure that monitoring is conducted in
the best interests of the participant.
Specify:

Character
Count: 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.

Methods for Discovery: Service
Plan Assurance/Sub-assurances

Sub-Assurances:

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/indicator the State will use to assess compliance
with the statutory assurance complete the following. Where possible,
include numerator/denominator. Each performance measure must be specific
to this waiver (i.e., data presented must be waiver specific).

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

Sub-assurance: The
State monitors service plan development in accordance with its policies
and procedures.

Performance Measures

For
each performance measure/indicator the State will use to assess compliance
with the statutory assurance complete the following. Where possible,
include numerator/denominator. Each performance measure must be specific
to this waiver (i.e., data presented must be waiver specific).

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

Sub-assurance: 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/indicator the State will use to assess compliance
with the statutory assurance complete the following. Where possible,
include numerator/denominator. Each performance measure must be specific
to this waiver (i.e., data presented must be waiver specific).

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

Sub-assurance: 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/indicator the State will use to assess compliance
with the statutory assurance complete the following. Where possible,
include numerator/denominator. Each performance measure must be specific
to this waiver (i.e., data presented must be waiver specific).

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

Sub-assurance:
Participants are afforded choice: Between waiver services and
institutional care; and between/among waiver services and
providers.

Performance Measures

For
each performance measure/indicator the State will use to assess compliance
with the statutory assurance complete the following. Where possible,
include numerator/denominator. Each performance measure must be specific
to this waiver (i.e., data presented must be waiver specific).

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.

If applicable, in the textbox below provide any necessary
additional information on the strategies employed by the State to
discover/identify problems/issues within the waiver program, including
frequency and parties responsible.

Character
Count: out of 6000

Methods for Remediation/Fixing
Individual Problems

Describe the State’s method for addressing individual
problems as they are discovered. Include information regarding responsible
parties and GENERAL methods for problem correction. In addition, provide
information on the methods used by the State to document these items.

Character Count: out of 6000

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):

State Medicaid
Agency

Weekly

Operating
Agency

Monthly

Sub-State
Entity

Quarterly

Other

Specify:

Annually

Continuously and
Ongoing

Other

Specify:

Timelines

When the State does not have all elements of the Quality
Improvement Strategy in place, provide timelines to design methods for
discovery and remediation related to the assurance of Financial Accountability
that are currently non-operational.

No

Yes

not selected

Please provide a
detailed strategy for assuring Administrative Authority, the specific timeline
for implementing identified strategies, and the parties responsible for its
operation.

Character
Count: out of 6000

Appendix E: Participant Direction of Services

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

Yes. This waiver provides participant
direction opportunities. Complete the remainder
of the Appendix.

No. This waiver does not provide participant
direction opportunities. Do not complete the
remainder of the Appendix.

not
selected

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):

Yes. The State requests that this waiver
be considered for Independence Plus designation.

No. Independence Plus designation is not
requested.

not
selected

Appendix E: Participant Direction of Services

E-1: Overview (1 of 13)

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

E-1: Overview (2 of 13)

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

E-1: Overview (3 of 13)

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

E-1: Overview (4 of 13)

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

E-1: Overview (5 of 13)

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

E-1: Overview (6 of 13)

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

E-1: Overview (7 of 13)

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

E-1: Overview (8 of 13)

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

E-1: Overview (9 of 13)

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

E-1: Overview (10 of 13)

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

E-1: Overview (11 of 13)

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

E-1: Overview (12 of 13)

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

E-1: Overview (13 of 13)

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

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

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

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

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

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

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

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

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

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

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

Appendix E: Participant Direction of Services

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

Answers provided in Appendix E-0 indicate that you do not need
to submit Appendix E.

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. Describe how the
individual (or his/her legal representative) is informed of the opportunity to
request a fair hearing under 42 CFR Part 431, Subpart E. Specify the notice(s)
that are used to offer individuals the opportunity to request a Fair Hearing.
State laws, regulations, policies and notices referenced in the description are
available to CMS upon request through the operating or Medicaid
agency.

Character
Count: out of 12000

Appendix F: Participant-Rights

Appendix F-2: Additional Dispute Resolution Process

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:

No. This Appendix does not
apply

Yes. The State operates an additional
dispute resolution process

not selected

Description of Additional Dispute Resolution
Process. Describe the additional dispute resolution process,
including: (a) the State agency that operates the process; (b) the nature of
the process (i.e., procedures and timeframes), including the types of disputes
addressed through the process; and, (c) how the right to a Medicaid Fair
Hearing is preserved when a participant elects to make use of the process:
State laws, regulations, and policies referenced in the description are
available to CMS upon request through the operating or Medicaid
agency.

Character
Count: out of
12000

Appendix F: Participant-Rights

Appendix F-3: State Grievance/Complaint System

Operation of Grievance/Complaint
System. Select one:

No. This Appendix does not apply

Yes. The State operates a grievance/complaint
system that affords participants the opportunity to register grievances or
complaints concerning the provision of services under this
waiver

not selected

Operational Responsibility. Specify the State agency that is responsible for the
operation of the grievance/complaint system:

Character
Count: out of 4000

Description of System. Describe the grievance/complaint system, including: (a) the
types of grievances/complaints that participants may register; (b) the process
and timelines for addressing grievances/complaints; and, (c) the mechanisms
that are used to resolve grievances/complaints. State laws, regulations, and
policies referenced in the description are available to CMS upon request
through the Medicaid agency or the operating agency (if
applicable).

Character
Count: out of 12000

Appendix G: Participant Safeguards

Appendix G-1: Response to Critical Events or Incidents

Critical Event or Incident Reporting and
Management Process. Indicate whether the State
operates Critical Event or Incident Reporting and Management Process that
enables the State to collect information on sentinel events occurring in the
waiver program.Select one:

not selected

Yes. The State operates a Critical Event or
Incident Reporting and Management Process (complete Items b through e)

No. This Appendix does not apply
(do not complete Items b through e)

If the State does not operate a Critical Event or Incident
Reporting and Management Process, describe the process that the State uses to
elicit information on the health and welfare of individuals served through the
program.

Character Count: out of 12000

State Critical Event or Incident Reporting
Requirements. Specify the types of
critical events or incidents (including alleged abuse, neglect and
exploitation) that the State requires to be reported for review and follow-up
action by an appropriate authority, the individuals and/or entities that are
required to report such events and incidents and the timelines for reporting.
State laws, regulations, and policies that are referenced are available to CMS
upon request through the Medicaid agency or the operating agency (if
applicable).

Character
Count: out of 24000

Participant Training and Education.
Describe how training and/or information is provided to
participants (and/or families or legal representatives, as appropriate)
concerning protections from abuse, neglect, and exploitation, including how
participants (and/or families or legal representatives, as appropriate) can
notify appropriate authorities or entities when the participant may have
experienced abuse, neglect or exploitation.

Character
Count: out of 12000

Responsibility for Review of and Response to
Critical Events or Incidents. Specify the entity (or
entities) that receives reports of critical events or incidents specified in
item G-1-a, the methods that are employed to evaluate such reports, and the
processes and time-frames for responding to critical events or incidents,
including conducting investigations.

Character
Count: out of 12000

Responsibility for Oversight of Critical
Incidents and Events. Identify the State
agency (or agencies) responsible for overseeing the reporting of and response
to critical incidents or events that affect waiver participants, how this
oversight is conducted, and how frequently.

Character
Count: out of 12000

Appendix G: Participant Safeguards

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

Use of Restraints or Seclusion.
(Select one):

The State does not permit or prohibits the
use of restraints or seclusion

Specify the State
agency (or agencies) responsible for detecting the unauthorized use of
restraints or seclusion and how this oversight is conducted and its
frequency:

Character
Count: out of
12000

The use of restraints or seclusion is
permitted during the course of the delivery of waiver services. Complete Items G-2-a-i and G-2-a-ii.

not selected

Safeguards Concerning the Use of Restraints or
Seclusion. Specify the safeguards that the State has established
concerning the use of each type of restraint (i.e., personal restraints,
drugs used as restraints, mechanical restraints or seclusion). State laws,
regulations, and policies that are referenced are available to CMS upon
request through the Medicaid agency or the operating agency (if
applicable).

Character
Count: out of 12000

State Oversight Responsibility.
Specify the State agency (or agencies) responsible for
overseeing the use of restraints or seclusion and ensuring that State
safeguards concerning their use are followed and how such oversight is
conducted and its frequency:

Character
Count: out of
12000

Appendix G: Participant Safeguards

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

Use of Restrictive Interventions.
(Select one):

The State does not permit or prohibits the
use of restrictive interventions

Specify the State
agency (or agencies) responsible for detecting the unauthorized use of
restrictive interventions and how this oversight is conducted and its
frequency:

Character
Count: out of
12000

The use of restrictive interventions is
permitted during the course of the delivery of waiver services Complete Items G-2-b-i and G-2-b-ii.

not selected

Safeguards Concerning the Use of Restrictive
Interventions. Specify the safeguards
that the State has in effect concerning the use of interventions that
restrict participant movement, participant access to other individuals,
locations or activities, restrict participant rights or employ aversive
methods (not including restraints or seclusion) to modify behavior. State
laws, regulations, and policies referenced in the specification are
available to CMS upon request through the Medicaid agency or the operating
agency.

Character
Count: out of 20000

State Oversight Responsibility.
Specify the State agency (or agencies) responsible for
monitoring and overseeing the use of restrictive interventions and how this
oversight is conducted and its frequency:

Character
Count: out of
20000

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.

Applicability. Select one:

No. This Appendix is not applicable
(do not complete the remaining items)

Yes. This Appendix applies (complete the remaining items)

not selected

Medication Management and Follow-Up

Responsibility. Specify the entity (or entities) that have ongoing
responsibility for monitoring participant medication regimens, the methods
for conducting monitoring, and the frequency of monitoring.

Character
Count: out of 12000

Methods of State Oversight and
Follow-Up. Describe: (a) the
method(s) that the State uses to ensure that participant medications are
managed appropriately, including: (a) the identification of potentially
harmful practices (e.g., the concurrent use of contraindicated medications);
(b) the method(s) for following up on potentially harmful practices; and,
(c) the State agency (or agencies) that is responsible for follow-up and
oversight.

Character
Count: out of
12000

Appendix G: Participant Safeguards

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

Medication Administration by Waiver Providers

Complete Appendix G-3-a before completing
this section

Provider Administration of
Medications. Select one:

Not applicable. (do not complete the remaining items)

Waiver providers are responsible for
the administration of medications to waiver participants who cannot
self-administer and/or have responsibility to oversee participant
self-administration of medications. (complete the remaining items)

not selected

State Policy. Summarize the State policies that apply to the
administration of medications by waiver providers or waiver provider
responsibilities when participants self-administer medications, including
(if applicable) policies concerning medication administration by non-medical
waiver provider personnel. State laws, regulations, and policies referenced
in the specification are available to CMS upon request through the Medicaid
agency or the operating agency (if applicable).

Character
Count: out of
12000

Medication Error Reporting.
Select one of the following:

Providers that are responsible for
medication administration are required to both record and report medication
errors to a State agency (or agencies).

Complete the following three items:

(a) Specify State
agency (or agencies) to which errors are reported:

Character
Count: out of
12000

(b) Specify the
types of medication errors that providers are required to record:

Character
Count: out of
12000

(c) Specify the
types of medication errors that providers must report to the
State:

Character
Count: out of
12000

Providers responsible for medication
administration are required to record medication errors but make information
about medication errors available only when requested by the State.

Specify the
types of medication errors that providers are required to
record:

Character
Count: out of
12000

not selected

State Oversight Responsibility.
Specify the State
agency (or agencies) responsible for monitoring the performance of waiver
providers in the administration of medications to waiver participants and
how monitoring is performed and its frequency.

Character
Count: 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.

Methods for Discovery: Health and
Welfare

The State, on an ongoing
basis, identifies, addresses and seeks to prevent the occurrence of abuse,
neglect and exploitation.

Performance Measures

For each performance
measure/indicator the State will use to assess compliance with the statutory
assurance complete the following. Where possible, include
numerator/denominator. Each performance measure must be specific to this
waiver (i.e., data presented must be waiver specific).

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.

If applicable, in the textbox below provide any necessary
additional information on the strategies employed by the State to
discover/identify problems/issues within the waiver program, including
frequency and parties responsible.

Character
Count: out of 6000

Methods for Remediation/Fixing
Individual Problems

Describe the State’s method for addressing individual
problems as they are discovered. Include information regarding responsible
parties and GENERAL methods for problem correction. In addition, provide
information on the methods used by the State to document these items.

Character Count: out of 6000

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):

State Medicaid
Agency

Weekly

Operating
Agency

Monthly

Sub-State
Entity

Quarterly

Other

Specify:

Annually

Continuously and
Ongoing

Other

Specify:

Timelines

When the State does not have all elements of the Quality
Improvement Strategy in place, provide timelines to design methods for
discovery and remediation related to the assurance of Financial Accountability
that are currently non-operational.

No

Yes

not selected

Please provide a
detailed strategy for assuring Administrative Authority, the specific timeline
for implementing identified strategies, and the parties responsible for its
operation.

Character
Count: 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.

Quality Improvement is a critical operational feature that an organization
employs to continually determine whether it operates in accordance with the
approved design of its program, meets statutory and regulatory assurances and
requirements, achieves desired outcomes, and identifies opportunities for
improvement.

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 QMS discovery and remediation sections throughout the
application (located in Appendices A, B, C, D, G, and I) , a state spells out:

The evidence based discovery activities that will be conducted for each of
the six major waiver assurances;

The remediation activities followed to correct individual
problems identified in the implementation of each of the assurances;

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 QMS 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 QMS spans more than one waiver, the State must be able to
stratify information that is related to each approved waiver program.

Appendix H: Quality Improvement Strategy (2
of 2)

H-1: Systems Improvement

System Improvements

Describe the
process(es) for trending, prioritizing, and implementing system improvements
(i.e., design changes) prompted as a result of an analysis of discovery and
remediation information.

Character
Count: out of 12000

System Improvement Activities

Responsible
Party (check
each that applies):

Frequency of
Monitoring and Analysis (check each that applies):

State Medicaid
Agency

Weekly

Operating
Agency

Monthly

Sub-State
Entity

Quarterly

Quality Improvement
Committee

Annually

Other

Specify:

Other

Specify:

System Design Changes

Describe the process
for monitoring and analyzing the effectiveness of system design changes.
Include a description of the various roles and responsibilities involved in
the processes for monitoring & assessing system design changes. If
applicable, include the State’s targeted standards for systems
improvement.

Character
Count: out of 12000

Describe the process
to periodically evaluate, as appropriate, the Quality Improvement
Strategy.

Character
Count: out of 12000

Appendix I: Financial Accountability

I-1: Financial Integrity and Accountability

Financial Integrity. Describe the methods that are
employed to ensure the integrity of payments that have been made for waiver
services, including: (a) requirements concerning the independent audit of
provider agencies; (b) the financial audit program that the state conducts to
ensure the integrity of provider billings for Medicaid payment of waiver
services, including the methods, scope and frequency of audits; and, (c) the
agency (or agencies) responsible for conducting the financial audit program.
State laws, regulations, and policies referenced in the description are
available to CMS upon request through the Medicaid agency or the operating
agency (if applicable).

Character Count: 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.

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.

Performance Measures

For each performance
measure/indicator the State will use to assess compliance with the statutory
assurance complete the following. Where possible, include
numerator/denominator. Each performance measure must be specific to this
waiver (i.e., data presented must be waiver specific).

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.

If applicable, in the textbox below provide any necessary
additional information on the strategies employed by the State to
discover/identify problems/issues within the waiver program, including
frequency and parties responsible.

Character
Count: out of 6000

Methods for Remediation/Fixing
Individual Problems

Describe the State’s method for addressing individual
problems as they are discovered. Include information regarding responsible
parties and GENERAL methods for problem correction. In addition, provide
information on the methods used by the State to document these items.

Character Count: out of 6000

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):

State Medicaid
Agency

Weekly

Operating
Agency

Monthly

Sub-State
Entity

Quarterly

Other

Specify:

Annually

Continuously and
Ongoing

Other

Specify:

Timelines

When the State does not have all elements of the Quality
Improvement Strategy in place, provide timelines to design methods for
discovery and remediation related to the assurance of Financial Accountability
that are currently non-operational.

No

Yes

not selected

Please provide a
detailed strategy for assuring Administrative Authority, the specific timeline
for implementing identified strategies, and the parties responsible for its
operation.

Character
Count: out of 6000

Appendix I: Financial Accountability

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

Rate Determination Methods. In two pages or less, describe the methods that are
employed to establish provider payment rates for waiver services and the
entity or entities that are responsible for rate determination. Indicate any
opportunity for public comment in the process. If different methods are
employed for various types of services, the description may group services for
which the same method is employed. State laws, regulations, and policies
referenced in the description are available upon request to CMS through the
Medicaid agency or the operating agency (if applicable).

Character Count: out of 12000

Flow of Billings. Describe the flow of billings for waiver services,
specifying whether provider billings flow directly from providers to the
State's claims payment system or whether billings are routed through other
intermediary entities. If billings flow through other intermediary entities,
specify the entities:

Character Count: out of 6000

Appendix I: Financial Accountability

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

Certifying Public Expenditures
(select one):

No. State or local government agencies do not
certify expenditures for waiver services.

Yes. State or local government agencies directly
expend funds for part or all of the cost of waiver services and certify
their State government expenditures (CPE) in lieu of billing that amount
to Medicaid.

Select at least one:

Certified Public Expenditures (CPE) of State Public
Agencies.

Specify: (a) the State government agency or agencies that
certify public expenditures for waiver services; (b) how it is assured that
the CPE is based on the total computable costs for waiver services; and, (c)
how the State verifies that the certified public expenditures are eligible for
Federal financial participation in accordance with 42 CFR
§433.51(b).(Indicate source of revenue for CPEs in Item
I-4-a.)

Character Count: out of 6000

Certified Public Expenditures (CPE) of Local Government
Agencies.

Specify: (a) the local
government agencies that incur certified public expenditures for waiver
services; (b) how it is assured that the CPE is based on total computable
costs for waiver services; and, (c) how the State verifies that the certified
public expenditures are eligible for Federal financial participation in
accordance with 42 CFR §433.51(b). (Indicate source
of revenue for CPEs in Item I-4-b.)

Character
Count: out of 6000

Appendix I: Financial Accountability

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

Billing Validation Process. Describe the process for validating provider billings to
produce the claim for federal financial participation, including the
mechanism(s) to assure that all claims for payment are made only: (a) when the
individual was eligible for Medicaid waiver payment on the date of service;
(b) when the service was included in the participant's approved service plan;
and, (c) the services were provided:

Character
Count: out of 6000

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)

Method of payments -- MMIS (select
one):

Payments for all waiver services are
made through an approved Medicaid Management Information System
(MMIS).

Payments for some, but not all, waiver
services are made through an approved MMIS.

Specify: (a) the
waiver services that are not paid through an approved MMIS; (b) the process
for making such payments and the entity that processes payments; (c) and how
an audit trail is maintained for all state and federal funds expended outside
the MMIS; and, (d) the basis for the draw of federal funds and claiming of
these expenditures on the CMS-64:

Character
Count: out of
6000

Payments for waiver services are not
made through an approved MMIS.

Specify: (a) the
process by which payments are made and the entity that processes payments; (b)
how and through which system(s) the payments are processed; (c) how an audit
trail is maintained for all state and federal funds expended outside the MMIS;
and, (d) the basis for the draw of federal funds and claiming of these
expenditures on the CMS-64:

Character
Count: out of
6000

Payments for waiver services are made by
a managed care entity or entities. The managed care entity is paid a monthly
capitated payment per eligible enrollee through an approved MMIS.

Describe how payments
are made to the managed care entity or entities:

Character
Count: out of
6000

not
selected

Appendix I: Financial Accountability

I-3: Payment (2 of 7)

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):

The Medicaid agency makes payments directly and does not use
a fiscal agent (comprehensive or limited) or a managed care entity or
entities.

The Medicaid agency pays
providers through the same fiscal agent used for the rest of the Medicaid
program.

The Medicaid agency pays providers of some or all waiver
services through the use of a limited fiscal agent.

Specify the
limited fiscal agent, the waiver services for which the limited fiscal agent
makes payment, the functions that the limited fiscal agent performs in paying
waiver claims, and the methods by which the Medicaid agency oversees the
operations of the limited fiscal agent:

Character
Count: out of
6000

Providers are paid by a managed care entity or entities for
services that are included in the State's contract with the
entity.

Specify how
providers are paid for the services (if any) not included in the State's
contract with managed care entities.

Character
Count: out of
6000

Appendix I: Financial Accountability

I-3: Payment (3 of 7)

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:

No. The State does not make supplemental or
enhanced payments for waiver services.

Yes. The State makes supplemental or
enhanced payments for waiver services.

Describe: (a) the
nature of the supplemental or enhanced payments that are made and the waiver
services for which these payments are made; (b) the types of providers to
which such payments are made; (c) the source of the non-Federal share of the
supplemental or enhanced payment; and, (d) whether providers eligible to
receive the supplemental or enhanced payment retain 100% of the total
computable expenditure claimed by the State to CMS. Upon request, the State
will furnish CMS with detailed information about the total amount of
supplemental or enhanced payments to each provider type in the
waiver.

Character
Count: out of 6000

Appendix I: Financial Accountability

I-3: Payment (4 of 7)

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

No. State or local government providers do
not receive payment for waiver services. Do
not complete Item I-3-e.

Yes. State or local government providers
receive payment for waiver services. Complete
Item I-3-e.

Specify the types of State or local government providers
that receive payment for waiver services and the services that the State or
local government providers furnish: Complete item
I-3-e.

Character
Count: out of 4000

not selected

Appendix I: Financial Accountability

I-3: Payment (5 of 7)

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:

Complete Appendix I-3-d before completing this section

The amount paid to State or local
government providers is the same as the amount paid to private providers
of the same service.

The amount paid to State or local
government providers differs from the amount paid to private providers
of the same service. No public provider receives payments that in the
aggregate exceed its reasonable costs of providing waiver
services.

The amount paid to State or local
government providers differs from the amount paid to private providers
of the same service. When a State or local government provider receives
payments (including regular and any supplemental payments) that in the
aggregate exceed the cost of waiver services, the State recoups the
excess and returns the federal share of the excess to CMS on the
quarterly expenditure report.

Describe the
recoupment process:

Character
Count: out of
6000

Appendix I: Financial Accountability

I-3: Payment (6 of 7)

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:

Providers receive and retain 100 percent
of the amount claimed to CMS for waiver services.

Providers do not receive and retain 100
percent of the amount claimed to CMS for waiver services.

Provide a full
description of the billing, claims, or payment processes that result in less
than 100% reimbursement of providers. Include: (a) the methodology for reduced
or returned payments; (b) a complete listing of types of providers, the amount
or percentage of payments that are reduced or returned; and, (c) the
disposition and use of the funds retained or returned to the State (i.e.,
general fund, medical services account, etc.):

Character
Count: out of
12000

Providers are paid by a managed care
entity (or entities) that is paid a monthly capitated payment.

Specify whether
the monthly capitated payment to managed care entities is reduced or returned
in part to the State.

Character
Count: out of
12000

not
selected

Appendix I: Financial Accountability

I-3: Payment (7 of 7)

Additional Payment Arrangements

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

No. The State does not provide that
providers may voluntarily reassign their right to direct payments to a
governmental agency.

Yes. Providers may voluntarily
reassign their right to direct payments to a governmental agency as
provided in 42 CFR §447.10(e).

Specify the
governmental agency (or agencies) to which reassignment may be
made.

Character
Count: out of
4000

Organized Health Care Delivery
System. Select one:

No. The State does not employ Organized
Health Care Delivery System (OHCDS) arrangements under the provisions
of 42 CFR §447.10.

Yes. The waiver provides for the use of
Organized Health Care Delivery System arrangements under the
provisions of 42 CFR §447.10.

Specify the
following: (a) the entities that are designated as an OHCDS and how these
entities qualify for designation as an OHCDS; (b) the procedures for direct
provider enrollment when a provider does not voluntarily agree to contract
with a designated OHCDS; (c) the method(s) for assuring that participants
have free choice of qualified providers when an OHCDS arrangement is
employed, including the selection of providers not affiliated with the
OHCDS; (d) the method(s) for assuring that providers that furnish services
under contract with an OHCDS meet applicable provider qualifications under
the waiver; (e) how it is assured that OHCDS contracts with providers meet
applicable requirements; and, (f) how financial accountability is assured
when an OHCDS arrangement is used:

Character
Count: out of
18000

Contracts with MCOs, PIHPs or PAHPs.
Select one:

The State does not contract with MCOs,
PIHPs or PAHPs for the provision of waiver services.

The State contracts with a Managed Care
Organization(s) (MCOs) and/or prepaid inpatient health plan(s) (PIHP) or
prepaid ambulatory health plan(s) (PAHP) under the provisions of §1915(a)(1)
of the Act for the delivery of waiver and other services. Participants may
voluntarily elect to receive waiver and other services through such MCOs or
prepaid health plans. Contracts with these health plans are on file at the
State Medicaid agency.

Describe: (a) the MCOs
and/or health plans that furnish services under the provisions of
§1915(a)(1); (b) the geographic areas served by these plans; (c) the waiver
and other services furnished by these plans; and, (d) how payments are made
to the health plans.

Character
Count: out of
18000

This waiver is a part of a concurrent
§1915(b)/§1915(c) waiver. Participants are required to obtain waiver and
other services through a MCO and/or prepaid inpatient health plan (PIHP) or
a prepaid ambulatory health plan (PAHP). The §1915(b) waiver specifies the
types of health plans that are used and how payments to these plans are
made.

not
selected

Appendix I: Financial Accountability

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

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:

Appropriation of State
Tax Revenues to the State Medicaid agency

Appropriation of State Tax Revenues to a State Agency other
than the Medicaid Agency.

If the source of
the non-federal share is appropriations to another state agency (or agencies),
specify: (a) the State entity or agency receiving appropriated funds and (b)
the mechanism that is used to transfer the funds to the Medicaid Agency or
Fiscal Agent, such as an Intergovernmental Transfer (IGT), including any
matching arrangement, and/or, indicate if the funds are directly expended by
State agencies as CPEs, as indicated in Item I-2-c:

Character
Count: out of
6000

Other State Level Source(s) of Funds.

Specify: (a) the
source and nature of funds; (b) the entity or agency that receives the funds;
and, (c) the mechanism that is used to transfer the funds to the Medicaid
Agency or Fiscal Agent, such as an Intergovernmental Transfer (IGT), including
any matching arrangement, and/or, indicate if funds are directly expended by
State agencies as CPEs, as indicated in Item I-2- c:

Character
Count: out of
6000

Appendix I: Financial Accountability

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

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:

Not Applicable. There are no local
government level sources of funds utilized as the non-federal
share.

Applicable

Check each that applies:

Not Applicable. There are no non-State level sources of funds
for the non-federal share.

Appropriation of Local Government Revenues.

Specify: (a) the
local government entity or entities that have the authority to levy taxes or
other revenues; (b) the source(s) of revenue; and, (c) the mechanism that is
used to transfer the funds to the Medicaid Agency or Fiscal Agent, such as an
Intergovernmental Transfer (IGT), including any matching arrangement (indicate
any intervening entities in the transfer process), and/or, indicate if funds
are directly expended by local government agencies as CPEs, as specified in
Item I-2-c:

Character
Count: out of
6000

Other Local Government Level Source(s) of
Funds.

Specify: (a) the
source of funds; (b) the local government entity or agency receiving funds;
and, (c) the mechanism that is used to transfer the funds to the State
Medicaid Agency or Fiscal Agent, such as an Intergovernmental Transfer (IGT),
including any matching arrangement, and /or, indicate if funds are directly
expended by local government agencies as CPEs, as specified in Item I-2-
c:

Character
Count: out of
6000

not selected

Appendix I: Financial Accountability

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

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:

None of the specified sources of funds
contribute to the non-federal share of computable waiver costs

The following source(s) are used

Check each that applies:

None of the foregoing sources
of funds contribute to the non-federal share of computable waiver
costs.

Health care-related taxes or fees

Provider-related donations

Federal funds

For each source of
funds indicated above, describe the source of the funds in
detail:

Character
Count: out of 6000

not selected

Appendix I: Financial Accountability

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

Services Furnished in Residential
Settings. Select one:

No services under this waiver are
furnished in residential settings other than the private residence of the
individual.

As specified in Appendix C, the State
furnishes waiver services in residential settings other than the personal home
of the individual.

not selected

Method for Excluding the Cost of
Room and Board Furnished in Residential Settings. The following
describes the methodology that the State uses to exclude Medicaid payment for
room and board in residential settings:

Character
Count: 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:

No. The State does not reimburse for the rent and
food expenses of an unrelated live-in personal caregiver who resides in
the same household as the participant.

Yes. Per 42 CFR §441.310(a)(2)(ii), the State will
claim FFP for the additional costs of rent and food that can be reasonably
attributed to an unrelated live-in personal caregiver who resides in the
same household as the waiver participant. The State describes its coverage
of live-in caregiver in Appendix C-3 and the costs attributable to rent
and food for the live-in caregiver are reflected separately in the
computation of factor D (cost of waiver services) in Appendix J. FFP for
rent and food for a live-in caregiver will not be claimed when the
participant lives in the caregiver's home or in a residence that is owned
or leased by the provider of Medicaid
services.

The following is an explanation of: (a) the method used to
apportion the additional costs of rent and food attributable to the unrelated
live-in personal caregiver that are incurred by the individual served on the
waiver and (b) the method used to reimburse these costs:

Character Count: out of 6000

Appendix I: Financial Accountability

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

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:

No. The State does not impose a co-payment
or similar charge upon participants for waiver services.

Yes. The State imposes a co-payment or
similar charge upon participants for one or more waiver services.

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):

Nominal
deductible

Coinsurance

Co-Payment

Other charge

Specify:

Character
Count: out of
6000

not selected

Appendix I: Financial Accountability

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

Co-Payment Requirements.

Participants Subject to Co-pay Charges for
Waiver Services.

Complete Appendix I-7-a before completing this
section

Appendix I: Financial Accountability

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

Co-Payment Requirements.

Amount of Co-Pay Charges for Waiver
Services.

Complete Appendix I-7-a before completing this
section

Appendix I: Financial Accountability

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

Co-Payment Requirements.

Cumulative Maximum Charges.

Complete Appendix I-7-a before completing this
section

Appendix I: Financial Accountability

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

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

No. The State does not impose a premium,
enrollment fee, or similar cost-sharing arrangement on waiver
participants.

Yes. The State imposes a premium,
enrollment fee or similar cost-sharing
arrangement.

Describe in detail
the cost sharing arrangement, including: (a) the type of cost sharing (e.g.,
premium, enrollment fee); (b) the amount of charge and how the amount of the
charge is related to total gross family income; (c) the groups of participants
subject to cost-sharing and the groups who are excluded; and, (d) the
mechanisms for the collection of cost-sharing and reporting the amount
collected on the CMS 64:

Character
Count: out of
12000

Appendix J: Cost Neutrality Demonstration

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

Composite Overview.
Complete the fields in Cols.
3, 5 and 6 in the following table for each waiver year. The fields in Cols. 4, 7
and 8 are auto-calculated based on entries in Cols 3, 5, and 6. The fields in
Col. 2 are auto-calculated using the Factor D data from the J-2d Estimate of
Factor D tables. Col. 2 fields will be populated ONLY when the Estimate of
Factor D tables in J-2d have been completed.

Level(s) of Care:

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

0.00

0.00

0.00

2

0.00

0.00

0.00

3

0.00

0.00

0.00

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (1 of 7)

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 Number Unduplicated Number of Participants
(from Item B-3-a)

Distribution of Unduplicated Participants by
Level of Care (if applicable)

Year 1

Year 2

Year 3

Appendix J: Cost Neutrality Demonstration

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

Average Length of Stay. Describe the basis of the estimate of the average length of stay
on the waiver by participants in item J-2-a.

Character Count:
out of 6000

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (3 of 7)

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

Factor D Derivation. The estimates of Factor D
for each waiver year are located in Item J-2-d. The basis for these
estimates is as follows:

Character Count: out of 12000

Factor D' Derivation. The estimates of Factor D'
for each waiver year are included in Item J-1. The basis of these estimates
is as follows:

Character Count: out of 12000

Factor G Derivation. The estimates of Factor G
for each waiver year are included in Item J-1. The basis of these estimates
is as follows:

Character Count: out of 12000

Factor G' Derivation. The estimates of Factor G'
for each waiver year are included in Item J-1. The basis of these estimates
is as follows:

Character Count: out of 12000

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (4 of 7)

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.
There
are no services defined for this waiver.

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (5 of 7)

Estimate of Factor D.

i. Non-Concurrent
Waiver. Complete the following table for each waiver year. Enter
data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fields
for all the Waiver Service/Component items. Select Save and Calculate to
automatically calculate and populate the Component Costs and Total Costs
fields. All fields in this table must be completed in order to populate the
Factor D fields in the J-1 Composite Overview table.

Waiver Year:
Year 1
There are no services defined for this
waiver. To complete this section please go to and add your services.

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (6 of 7)

Estimate of Factor D.

i. Non-Concurrent
Waiver. Complete the following table for each waiver year. Enter
data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fields
for all the Waiver Service/Component items. Select Save and Calculate to
automatically calculate and populate the Component Costs and Total Costs
fields. All fields in this table must be completed in order to populate the
Factor D fields in the J-1 Composite Overview table.

Waiver Year:
Year 2
There are no services defined for this
waiver. To complete this section please go to and add your services.

Appendix J: Cost Neutrality Demonstration

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

Estimate of Factor D.

i. Non-Concurrent
Waiver. Complete the following table for each waiver year. Enter
data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fields
for all the Waiver Service/Component items. Select Save and Calculate to
automatically calculate and populate the Component Costs and Total Costs
fields. All fields in this table must be completed in order to populate the
Factor D fields in the J-1 Composite Overview table.

Waiver Year:
Year 3
There are no services defined for this
waiver. To complete this section please go to and add your services.