CMS-10398 (#40) 40 Sample Balancing Incentive Report

Balancing Incentive Program GU.0132.R00.00

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MMDL: Balancing Incentive Program
Report Date
This report provides information regarding the Balancing Incentive Program as of the following date:
09/30/2012

Contacts
Please enter contact information for key individuals responsible for the State's Balancing Incentive Program.
State Medicaid Director

Name:

John Doe

Title:
Organization:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Fax:
Email:

Balancing Incentive Program Project Director

Name:
Title:
Organization:
Address 1:
Address 2:
City:
State:
Zip:
Phone:

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Fax:
Email:

Lead Staff for No Wrong Door / Single Entry Point System (if different from project director)

Name:
Title:
Organization:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Fax:
Email:

Lead Staff for Core Standardized Assessment (if different from project director)

Name:
Title:
Organization:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Fax:
Email:

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Lead Staff for Conflict-Free Case Management (if different from project director)

Name:
Title:
Organization:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Fax:
Email:

Report Preparer
Balancing Incentive Program Project Director
Lead Staff for No Wrong Door / Single Entry Point System (if different from project director)
Lead Staff for Core Standardized Assessment (if different from project director)
Lead Staff for Conflict-Free Case Management (if different from project director)
Other
Name:
Title:
Organization:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Fax:
Email:

Structural Changes

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The Structural Changes section collects the State's progress toward implementing the State's previously submitted Work Plan.
This section is organized according to the Work Plan Template, Appendix E of The Balancing Incentive Program:
Implementation Manual.
General No Wrong Door/Single Entry Point (NWD/SEP) Structure (page 1 of 2)
1. Develop standardized informational materials that NWD/SEPs provide to individuals:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables:

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

2. Train all participating staff on eligibility determination and enrollment processes:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

This task is not yet complete.

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Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

3. Detailed system design for the process to guide a person through assessment and eligibility determination (i.e., single
eligibility coordinator, case management system, or otherwise coordinated process):

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

Structural Changes
General No Wrong Door/Single Entry Point (NWD/SEP) Structure (page 2 of 2)

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4. Selection of vendor to develop the automated system for the process to guide a person through assessment and
eligibility determination (i.e., single eligibility coordinator, case management system, or otherwise coordinated
process):

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

The task is not applicable because the system will not be automated or state staff will develop the system.

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

This task is not yet complete.
Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

5. Pilot implementation and testing of the process to guide a person through assessment and eligibility determination (i.e.,
single eligibility coordinator, case management system, or otherwise coordinated process):

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.
This task is not yet complete.
Estimated percentage complete:

%

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Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

6. Process to guide a person through assessment and eligibility determination (i.e., single eligibility coordinator, case
management system, or otherwise coordinated process) is implemented statewide:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

7. System updates for the process to guide a person through assessment and eligibility determination (i.e., single
eligibility coordinator, case management system, or otherwise coordinated process).
The State intends to seek CMS approval to amend what will be submitted as deliverables for this


task.

Deliverables: (Please note any variance from Deliverables in the Work Plan)

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Describe changes to the system that were implemented:

Describe experienced or anticipated challenges:

Describe the State's plan to address the challenges described above:

Structural Changes
General No Wrong Door/Single Entry Point (NWD/SEP) Agencies
1. Develop and implement a Memorandum of Understanding (MOU) across the Medicaid Agency, Operating agencies,
and the NWD/SEPs:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.
This task is not yet complete.
Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

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2. Identify service shed coverage of all NWD/SEPs:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

3. Ensure NWD/SEPs are accessible to older adults and individuals with disabilities:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

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Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

Structural Changes
NWD/SEP System Website
1. Register a domain name, which provides the right to link content to a Uniform Resource Locator (URL):

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

2. Develop and incorporate content:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

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Enter the web site address (a.k.a. URL):

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

3. Incorporate the Level I screen (recommended, not required):
The task is in the Work Plan.

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.
This task is not yet complete.
Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

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Describe the State's plan to address the challenges described above:

Structural Changes
NWD/SEP System 1-800 Number
1. Contract 1-800 number service:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

Enter the 1-800 number:
This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.
This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

2. Train staff on answering phones, providing information, and conducting the Level I screen:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

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This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

Structural Changes
NWD/SEP System Advertising
1. Develop advertising plan:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

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Describe the State's plan to address the challenges described above:

2. Implement advertising plan:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

Structural Changes
Core Standardized Assessment
1. Develop questions for the Level I screen:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

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This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

2. Incorporate additional domains and topics into assessments if necessary:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.
This task is not yet complete.
Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

3. Train staff members at NWD/SEPs to coordinate the CSA:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

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Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.
This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

4. Identify qualified personnel to conduct the CSA:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can
be found in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

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Describe the State's plan to address the challenges described above:

5.

Deliverables: (Please note any variance from Deliverables in the Work Plan)

Describe changes to the Core Standardized Assessment that were implemented:

Describe experienced or anticipated challenges:

Describe the State's plan to address the challenges described above:

Structural Changes
Conflict-Free Case Management

Establish protocol for removing conflict of interest:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can be found
in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

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Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

Structural Changes
Sustainability

Develop sustainability plan:

When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can be found
in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

Structural Changes
Coordination with Health Information Exchange Information Technology (IT) System
1. Describe plans to coordinate the NWD/SEP system with the Health Information Exchange IT system:

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When does the State anticipate deliverables for this task will be submitted?
(mm/dd/yyyy)

Deliverables: (Please note any variance from Deliverables in the Work Plan)

This task was completed by the time the Program application was submitted. Supporting information can be found
in the application and/or Work Plan.
This task was completed after the Program application was submitted, and its status remains current.

This task is not yet complete.

Estimated percentage complete:

%

Describe progress for this task during the reporting period:

Describe experienced or anticipated challenges to completing this task:

Describe the State's plan to address the challenges described above:

2. Updates on coordination with the Health Information Exchange IT system, including the technological infrastructure.

Deliverables: (Please note any variance from Deliverables in the Work Plan)

Describe changes to coordination between the NWD/SEP system and the HIE IT system that occurred:

Describe experienced or anticipated challenges:

Describe the State's plan to address the challenges described above:

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Data Collection - List of Measures
The Data Collection section documents the State's progress toward collecting the Service, Quality, and Outcome
data the State agreed to collect as part of the State's Balancing Incentive Program application.
Service Measures:
Measure Name

Start of Measure Description

Implementation

Start of Measure Description

Implementation

Start of Measure Description

Implementation

Quality Measures:
Measure Name
Outcome Measures:
Measure Name

Expenditures Reporting, Current Reporting Period
The State used Attachment C of the Balancing Incentive Program Application Announcement to indicate eligibility
for the Balancing Incentive Program and the percentage of payments (i.e., 2% or 5%):
Enter the following information based on data the state will enter in the CMS 64 report for this reporting period. If this is
a State's first report, the reporting period for purposes of the following fields includes all completed quarters for which the
State has received Balancing Incentive Program payments.
Non-institutional LTSS on the CMS 64:

$

Institutional LTSS on the CMS 64:

$

Total qualified HCBS expenditures, demonstration services, and
supplemental services funded by the Money Follows the Person
demonstration:
$

Total LTSS:

$0.00

Percentage of LTSS for non-institutional services and supports:

0%

Change in percentage of LTSS for non-institutional services and
supports from previous quarter (assuming no prior period
adjustments):

N/A (first report)

Expenditures Reporting, Adjustments to Prior Reporting Periods

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The state reports prior period adjustments to previously submitted reports for the following reporting periods:

Reporting Period End Date
09/30/2012

Expenditures Reporting, Adjustments to Prior Reporting Periods Detail
This prior period adjustment applies to expenditures during the reporting period ending on the
following date:
09/30/2012
Enter the following information based on prior period adjustments the state will enter in the CMS 64 report
for this reporting period. Enter only the expenditures not previously reported; do not enter total expenditures.
Non-institutional LTSS on the CMS 64:

$

Institutional LTSS on the CMS 64:

$

Total qualified HCBS expenditures, demonstration services,
and supplemental services funded by the Money Follows the
Person demonstration:

$

Assurances
Explain how the State used the additional Federal funds paid to the State under the Balancing Incentive Program during
the reporting period for purposes of providing new or expanded offerings of non-institutionally-based LTSS, as
required in Section 10202(c)(4) of the Affordable Care Act.

The state attests it has not restricted eligibility standards, methodologies, or procedures for LTSS during
the reporting period.
Explain the restriction to eligibility implemented during the reporting period and, if applicable, how the State
remains in compliance with the Maintenance of Eligibility requirements in Section 10202(c)(3) of the Affordable
Care Act.

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