Form CMS-10398 #9 CMS-10398 #9 Application for Section 1915(b)(4) Waiver - Fee For Serv

Application for

Section 1915(b)(4) Waiver -

Fee For Service

Selective Contracting Program

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 . The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

April, 2012

Table of Contents

Facesheet 3

Section A – Waiver Program Description 4

Part I: Program Overview

Tribal Consultation 4

Waiver Services 4

Program Description 4

1. Statutory Authority 4

2. Delivery Systems 4

3. Restriction of Freedom of Choice 5

4. Populations Included in Waiver 5

Part II: Access

1. Timely Access Standards 6

2. Capacity Standards 6

3. Coordination and Continuity of Care Standards 6

Part III: Quality

Quality and Contract Monitoring 6

Part IV: Program Operations

A. Beneficiary Information 7

B. Individuals with Special Needs 7

Section B – Waiver Cost Effectiveness and Efficiency 8

Application for Section 1915(b)(4) Waiver -

Fee-For-Service (FFS) Selective Contracting Program

Facesheet

The State of ______________ requests a waiver/amendment under the authority of section 1915(b) of the Act. The Medicaid agency will directly operate the waiver.

The name of the waiver program is _________________________________.

(list each program name if the waiver authorizes more than one program.).

Type of request. This is:

___ an initial request for new waiver. All sections are filled.

___ a request to amend an existing waiver, which modifies Section/Part ____

___ a renewal request

Section A is:

___ replaced in full

___ carried over with no changes

___ changes noted in BOLD.

Section B is:

___ replaced in full

___ carried over with no changes

___ changes noted in BOLD.

Effective Dates: This waiver/renewal/amendment is requested for a period of ____ years beginning ____________and ending ____________.

State Contact: The State contact person for this waiver is ______________________ and can be reached by telephone at (___)________, or fax at (___)_____________, or e-mail at _________________. (list for each program)

Section A – Waiver Program Description

Part I: Program Overview

Tribal Consultation

Describe the efforts the State has made to ensure that Federally recognized tribes in the State are aware of and have had the opportunity to comment on this waiver proposal.

Waiver Services:

Please list all existing State plan services the State will provide through this selective contracting waiver.

Program Description:

Provide a brief description and history of the proposed selective contracting program or changes requested to the existing program. Please include the estimated number of enrollees served throughout the waiver period and describe the services included in the waiver.

A. Statutory Authority

1. Waiver Authority. The State is seeking authority under the following subsection of 1915(b):

___ 1915(b)(4) - FFS Selective Contracting program

2. Sections Waived. The State requests a waiver of these sections of 1902 of the Social Security Act:

a.___ Section 1902(a)(1) - Statewideness

b.___ Section 1902(a)(10)(B) - Comparability of Services

c.___ Section 1902(a)(23) - Freedom of Choice

d.___ Other Sections of 1902 – (please specify)

2. Delivery Systems

1. Reimbursement. Payment for the selective contracting program is:

___ the same as stipulated in the state plan

___ is different than stipulated in the state plan (please describe)

2. Procurement. The State selected the contractor in the following manner:

___ Competitive procurement

___ Open cooperative procurement

___ Sole source procurement

___ Other (please describe)

C. Restriction of Freedom of Choice

1. Provider Limitations.

___ Beneficiaries will be limited to a single provider in their service area.

___ Beneficiaries will be given a choice of providers in their service area.

(NOTE: Please indicate the area(s) of the State where the waiver program will be implemented)

2. State Standards.

Detail any difference between the state standards applied for through this waiver and those detailed in the State plan reimbursement documents (4.19 pages), the State Quality Strategy, or the waiver service contract.

D. Populations Included in Waiver

(may be modified as needed to fit the State’s specific circumstances)

1. Included Populations. The following populations are included in the waiver:

___ Section 1931 Children and Related Populations

___ Section 1931 Adults and Related Populations

___ Blind/Disabled Adults and Related Populations

___ Blind/Disabled Children and Related Populations

___ Aged and Related Populations

___ Foster Care Children

___ Title XXI CHIP Children

2. Excluded Populations. Indicate if any of the following populations are excluded from participating in the waiver:

___ Dual Eligibles

___ Poverty Level Pregnant Women

___ Individuals with other insurance

___ Individuals residing in a nursing facility or ICF/MR

___ Individuals with eligibility of less than 3 months

___ Individuals participating in a HCBS Waiver program

___ American Indians/Alaskan Natives

___ Special Needs Children (State Defined). Please provide this definition.

___ Individuals receiving retroactive eligibility

___ Other (Please define):

Part II: Access

1. Timely Access Standards

Describe how the State assures timely access to the services covered under the selective contracting program.

2. Capacity Standards

1. Describe how the State assures that provider capacity has not been negatively impacted by the selective contracting program.

2. Provide a detailed capacity analysis of the number of providers (such as by type, number of beds per facility for facility programs), or vehicles (by type, per contractor for non-emergency transportation programs), needed per location to assure sufficient capacity under the waiver program.

3. Coordination and Continuity of Care Standards

Describe how the State assures that continuity and coordination of care are not negatively impacted by the selective contracting program.

Part III: Quality

A. Quality and Contract Monitoring

1. Describe the State’s quality measurement standards.

Provide evidence that the State:

1. Regularly monitors to determine compliance.

2. Takes corrective action if there is a failure to comply.

2. Describe the State’s utilization measurement standards.

Provide evidence that the State:

1. Regularly monitors to determine compliance.

2. Takes corrective action if there is a failure to comply.

3. Describe the State’s timely access to care and services measurement standards.

Provide evidence that the State:

1. Regularly monitors to determine compliance.

2. Takes corrective action if there is a failure to comply.

4. Describe the State’s measurement standards or monitoring actions regarding the geographic location of providers and Medicaid enrollees.

Provide evidence that:

1. Provider availability is sufficient to provide adequate access to all services covered under the contract.

2. Services are available when medically necessary.

3. Network providers comply with the State’s timely access requirements.

Part IV: Program Operations

A. Beneficiary Information

Describe how beneficiaries will get information about the selective contracting program.

B. Individuals with Special Needs.

___ The State has special processes in place for persons with special needs

(Please provide detail).

Section B – Waiver Cost-Effectiveness and Efficiency

Efficient and economic provision of covered care and services:

1. Provide a description of the State’s efficient and economic provision of covered care and services.

2. Project the waiver expenditures for the upcoming waiver period.

Trend rate from current expenditures (or historical figures): ________%

Year 1 from: __/__/____ to __/__/____

Projected pre-waiver cost ________

Projected Plan cost ________

Delta: ________

Trend rate from current expenditures (or historical figures): ________%

Year 2 from: __/__/____ to __/__/____

(Use projected trend rate from previous year)

Projected pre-waiver cost ________

Projected Plan cost ________

Delta: ________

Year 3 (if applicable) from: __/__/____ to __/__/____

(For renewals, use trend rate from previous year and claims data from the CMS-64)

Projected pre-waiver cost ________

Projected Plan cost ________

Delta: ________

Year 4 (if applicable) from: __/__/____ to __/__/____

(For renewals, use trend rate from previous year and claims data from the CMS-64)

Projected pre-waiver cost ________

Projected Plan cost ________

Delta: ________

Year 5 (if applicable) from: __/__/____ to __/__/____

(For renewals, use trend rate from previous year and claims data from the CMS-64)

Projected pre-waiver cost ________

Projected Plan cost ________

Delta: ________

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