Track Changes: Application

Application for a §1915(c) Home and CommunityBased Services Waiver
PURPOSE OF THE HCBS WAIVER PROGRAM
The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in section §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 sState has broad discretion to design its waiver program
to address the needs of the waivers target population. Waiver services complement and/or supplement the services that are
available to participants through the Medicaid sState 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 sState 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)
A. The State of
requests approval for a Medicaid home and community-based services (HCBS) waiver under the
authority of section §1915(c) of the Social Security Act (the Act).
B. Program Title (optional - this title will be used to locate this waiver in the finder):

C. Type of Request: new
Requested Approval Period:(For new waivers requesting five year approval periods, the waiver must serve individuals
who are dually eligible for Medicaid and Medicare.)
3 years

5 years

New to replace waiver
Replacing Waiver Number:
Base Waiver Number:
Amendment Number
(if applicable):
Effective Date: (mm/dd/yy)
Draft ID:
D. Type of Waiver (select only one):
E. Proposed Effective Date: (mm/dd/yy)

PRA Disclosure Statement
The purpose of this application is for states to request a Medicaid Section 1915(c) home and
community-based services (HCBS) waiver. Section 1915(c) of the Social Security Act authorizes the
Secretary of Health and Human Services to waive certain specific Medicaid statutory requirements so

that a state may voluntarily offer HCBS to state-specified target group(s) of Medicaid beneficiaries who
need a level of institutional care that is provided under the Medicaid state plan. Under the Privacy Act
of 1974 any personally identifying information obtained will be kept private to the extent of the law.
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 0938-0449 (Expires: December 31, 2023). The time required to complete this
information collection is estimated to average 160 hours per response for a new waiver application and
75 hours per response for a renewal application, 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.

1. Request Information (2 of 3)
F. 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:

Inpatient psychiatric facility for individuals age 21 and under as provided in 42 CFR § 440.160
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:

Institution for Mental Disease for persons with mental illnesses aged 65 and older as provided in 42 CFR
§ 440.140
Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) (as defined in 42 CFR
§ 440.150)
If applicable, specify whether the state additionally limits the waiver to subcategories of the ICF/IID level of care:

1. Request Information (3 of 3)
G. 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 section §1915(a)(1)(a) of the Act and described in Appendix I
Waiver(s) authorized under section §1915(b) of the Act.
Specify the section §1915(b) waiver program and indicate whether a section §1915(b) waiver application has been
submitted or previously approved:

Specify the section §1915(b) authorities under which this program operates (check each that applies):
section §1915(b)(1) (mandated enrollment to managed care)
section §1915(b)(2) (central broker)
section §1915(b)(3) (employ cost savings to furnish additional services)
section §1915(b)(4) (selective contracting/limit number of
providers)
A program operated under section §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:

A program authorized under section §1915(i) of the Act.
A program authorized under section §1915(j) of
the Act. A program authorized under section
§1115 of the Act.
Specify the program:

H. Dual Eligiblity for Medicaid and Medicare.
Check if applicable:
This waiver provides services for individuals who are eligible for both Medicare and Medicaid.

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.

3. Components of the Waiver Request
The waiver application consists of the following components. Note: Item 3-E must be completed.
A. Waiver Administration and Operation. Appendix A specifies the administrative and operational structure of this
waiver.
B. 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.
C. Participant Services. Appendix C specifies the home and community-based waiver services that are furnished through
the waiver, including applicable limitations on such services.
D. 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).
E. 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.
F. 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.
G. Participant Safeguards. Appendix G describes the safeguards that the state has established to assure the health and
welfare of waiver participants in specified areas.
H. Quality Improvement Strategy. Appendix H contains the qQuality iImprovement sStrategy for this waiver.
I. 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.
J. Cost-Neutrality Demonstration. Appendix J contains the state's demonstration that the waiver is cost-neutral.

4. Waiver(s) Requested
A. Comparability. The state requests a waiver of the requirements contained in section §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.
B. Income and Resources for the Medically Needy. Indicate whether the state requests a waiver of section
§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
C. Statewideness. Indicate whether the state requests a waiver of the statewideness requirements in section §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:

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:

5. Assurances
In accordance with 42 CFR § 441.302, the state provides the following assurances to CMS:
A. 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:
1. As specified in Appendix C, adequate standards for all types of providers that provide services under this waiver;
2. 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,
3. Assurance that all facilities subject to section §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.
B. 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.
C. 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.
D. 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:
1. Informed of any feasible alternatives under the waiver; and,
2. 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.
E. 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. Costneutrality is demonstrated in Appendix J.
F. 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.
G. 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.
H. 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.

I. 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.
J. 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.
A. 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.
B. Inpatients. In accordance with 42 CFR § 441.301(b)(1)(ii), waiver services are not furnished to individuals who are inpatients of a hospital, nursing facility or ICF/IID.
C. 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.
D. Access to Services. The state does not limit or restrict participant access to waiver services except as provided in
Appendix C.
E. 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 section §1915(b) or another provision of the Act.
F. FFP Limitation. In accordance with 42 CFR Part§ 433 Subpart D, FFP is not claimed for services when another thirdparty (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, iIf 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.
G. Fair Hearing: The state provides the 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 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.
H. 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 qQuality iImprovement sStrategy specified
in Appendix H.
I. Public Input. Describe how the state secures public input into the development of the waiver:

J. 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 sState of the sState'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.
K. 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)
A. The Medicaid agency representative with whom CMS should communicate regarding the waiver is:
Last Name:

First Name:

Title:

Agency:

Address:

Address 2:

City:

State:
Zip:

Phone:
Ext:
Fax:

E-mail:

TTY

B. 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:
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 section §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:

Note: The Signature and Submission Date fields will be automatically completed when the State

Medicaid Director submits the application.
Last Name:

First Name:

Title:

Agency:

Address:

Address 2:

City:

State:
Zip:

Phone:
Ext:

TTY

Fax:

E-mail:

Attachments
Attachment #1: Transition Plan
Check the box next to any of the following changes from the current approved waiver. Check all boxes that apply.
Replacing an approved waiver with this waiver.
Combining waivers.
Splitting one waiver into two waivers.
Eliminating a service.
Adding or decreasing an individual cost limit pertaining to eligibility.
Adding or decreasing limits to a service or a set of services, as specified in Appendix C.
Reducing the unduplicated count of participants (Factor C).
Adding new, or decreasing, a limitation on the number of participants served at any point in time.
Making any changes that could result in some participants losing eligibility or being transferred to another waiver
under 1915(c) or another Medicaid authority.
Making any changes that could result in reduced services to participants.
Specify the transition plan for the waiver:

Attachment #2: Home and Community-Based Settings Waiver Transition Plan

Specify the state's process to bring this waiver into compliance with federal home and community-based (HCB) settings
requirements at 42 CFR 441.301(c)(4)-(5), and associated CMS guidance.
Consult with CMS for instructions before completing this item. This field describes the status of a transition process at the point in
time of submission. Relevant information in the planning phase will differ from information required to describe attainment of
milestones.
To the extent that the state has submitted a statewide HCB settings transition plan to CMS, the description in this field may
reference that statewide plan. The narrative in this field must include enough information to demonstrate that this waiver
complies with federal HCB settings requirements, including the compliance and transition requirements at 42 CFR 441.301(c)(6),
and that this submission is consistent with the portions of the statewide HCB settings transition plan that are germane to this
waiver. Quote or summarize germane portions of the statewide HCB settings transition plan as required.
Note that Appendix C-5 HCB Settings describes settings that do not require transition; the settings listed there meet federal HCB
setting requirements as of the date of submission. Do not duplicate that information here.
Update this field and Appendix C-5 when submitting a renewal or amendment to this waiver for other purposes. It is not
necessary for the state to amend the waiver solely for the purpose of updating this field and Appendix C-5. At the end of the state's
HCB settings transition process for this waiver, when all waiver settings meet federal HCB setting requirements, enter
"Completed" in this field, and include in Section C-5 the information on all HCB settings in the waiver.

Additional Needed Information (Optional)
Provide additional needed information for the waiver (optional):

Appendix A: Waiver Administration and Operation
1. 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).
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).

Appendix A: Waiver Administration and Operation
2. Oversight of Performance.
a. 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:
As indicated in section 1 of this appendix, the waiver is not operated by another division/unit within the
sState Medicaid agency. Thus, this section does not need to be completed.

b. 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:

Appendix A: Waiver Administration and Operation
3. 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.:

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

Appendix A: Waiver Administration and Operation
4. 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 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 sState

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:

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:

Appendix A: Waiver Administration and Operation
5. 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:

Appendix A: Waiver Administration and Operation
6. 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:

Appendix A: Waiver Administration and Operation
7. 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. Note: Medicaid eligibility determinations can only be performed by the State Medicaid Agency (SMA) or a
government agency delegated by the SMA in accordance with 42 CFR § 431.10. Thus, eligibility determinations for the
group described in 42 CFR § 435.217 (which includes a level-of-care assessment, because meeting a 1915(c) level of care
is a factor of determining Medicaid eligibility for the group) must comply with 42 CFR § 431.10. Non-governmental
entities can support administrative functions of the eligibility determination process that do not require discretion
including, for example, data entry functions, IT support, and implementation of a standardized level-of-care assessment

tool. States should ensure that any use of an assessment tool by a non-governmental entity to evaluate/determine an
individual’s required level-of-care involves no discretion by the non-governmental entity and that the development of the
requirements, rules, and policies operationalized by the tool are overseen by the state agency.

Function

Medicaid
Agency

Other State Operating
Agency

Contracted
Entity

Local Non-State
Entity

Medicaid
Agency

Other State Operating
Agency

Contracted
Entity

Local Non-State
Entity

Participant waiver enrollment

Function
Waiver enrollment managed against approved limits
Waiver expenditures managed against approved levels
Level of care waiver eligibility 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 sState’s quality improvement strategy, provide information in the following fields to detail the sState’s
methods for discovery and remediation.
a. 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.
i. Performance Measures
For each performance measure the sState will use to assess compliance with the statutory assurance, complete
the following. Performance measures for administrative authority should not duplicate measures found in other
appendices of the waiver application. As necessary and applicable, performance measures should focus on:
Uniformity of development/execution of provider agreements throughout all geographic areas covered by
the waiver
Equitable distribution of waiver openings in all geographic areas covered by the waiver
Compliance with HCB settings requirements and other new regulatory components (for waiver actions
submitted on or after March 17, 2014)
■

■

■

Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

Performance Measure:

Data Source (Select one):

If 'Other' is selected, specify:

Responsible Party for data
collection/generation(check
each that applies):

Frequency of data
collection/generation(check
each that applies):

Sampling Approach(check
each that applies):

State Medicaid
Agency

Weekly

100% Review

Operating Agency

Monthly

Less than 100%
Review

Sub-State Entity

Quarterly

Representative
Sample
Confidence
Interval =

Other
Specify:

Annually

Stratified
Describe Group:

Continuously and
Ongoing

Other
Specify:

Other
Specify:

Add another Data Source for this performance measure

Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (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:

Add another Performance measure (button to prompt another performance measure)

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

b. Methods for Remediation/Fixing Individual Problems
i. Describe the sState’s method for addressing individual problems as they are discovered. Include information

regarding responsible parties and GENERAL methods for problem correction and the state’s method for analyzing
information from individual problems, identifying systemic deficiencies, and implementing remediation actions.
In addition, provide information on the methods used by the state to document these items.

ii. 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:

c. Timelines
When the sState does not have all elements of the qQuality iImprovement sStrategy in place, provide timelines to design
methods for discovery and remediation related to the assurance of Administrative Authority that are currently nonoperational.
No
Yes
Please provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing
identified strategies, and the parties responsible for its operation.

Appendix B: Participant Access and Eligibility
B-1: Specification of the Waiver Target Group(s)
a. Target Group(s). Under the waiver of Section 1902(a)(10)(B) of the Act, the state limits waiver services to one or more
groups 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 or more waiver target groups, check each of the subgroups in the selected
target

group(s) 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 Sub Group

Minimum Age

Maximum Age
Maximum Age No Maximum Age
Limit
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
Intellectual Disability or Developmental Disability, or Both
Autism
Developmental Disability
Intellectual Disability
Mental Illness
Mental Illness
Serious Emotional Disturbance

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

c. 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:

Appendix B: Participant Access and Eligibility
B-2: Individual Cost Limit (1 of 2)
a. 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:

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.

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:

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

Other:
Specify:

Appendix B: Participant Access and Eligibility
B-2: Individual Cost Limit (2 of 2)
b. 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:

c. 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:

Other safeguard(s)
Specify:

Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served (1 of 4)
a. 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 costneutrality calculations in Appendix J:
Table: B-3-a
Waiver Year

Unduplicated Number of Participants

Year 1
Year 2
Year 3
Year 4
Year 5

b. 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
Year 1
Year 2
Year 3
Year 4
Year 5

Maximum Number of Participants Served
At Any Point During the Year

Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served (2 of 4)
c. 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 sState (select one):
Not applicable. The state does not reserve capacity.
The state reserves capacity for the following purpose(s).
Purpose(s) the state reserves capacity for:
Purposes

Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served (2 of 4)
Purpose (provide a title or short description to use for lookup):

Purpose (describe):

Describe how the amount of reserved capacity was determined:

The capacity that the sState reserves in each waiver year is specified in the following table:
Waiver Year
Year 1
Year 2
Year 3
Year 4
Year 5

Capacity Reserved

Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served (3 of 4)
d. 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.
e. 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:

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

Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served - Attachment #1 (4 of 4)

Waiver Phase-In/Phase-Out Schedule
Based on Waiver Proposed Effective Date:
a. The waiver is being (select one):
Phased-in
Phased-out
b. Phase-In/Phase-Out Time Schedule. Complete the following table:

Beginning (base) number of Participants:

Phase-In/Phase-Out Schedule
Waiver Year 1

Waiver Year 2

Unduplicated Number of Participants:
Month

Base Number of
Participants

Change

Unduplicated Number of Participants:
Participant
Limit

Month

Mar

Mar

Apr

Apr

May

May

Jun

Jun

Jul

Jul

Aug

Aug

Sep

Sep

Oct

Oct

Nov

Nov

Dec

Dec

Jan

Jan

Feb

Feb

Base Number of
Participants

Change

Participant
Limit

Waiver Year 4

Waiver Year 3

Unduplicated Number of Participants:

Unduplicated Number of Participants:
Month

Base Number of
Participants

Change

Participant
Limit

Month

Mar

Mar

Apr

Apr

May

May

Jun

Jun

Jul

Jul

Aug

Aug

Sep

Sep

Oct

Oct

Nov

Nov

Dec

Dec

Jan

Jan

Feb

Feb

Base Number of
Participants

Waiver Year 5
Unduplicated Number of Participants:
Month

Base Number of
Participants

Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb

c. Waiver Years Subject to Phase-In/Phase-Out Schedule

Change

Participant
Limit

Change

Participant
Limit

Year One Year Two Year Three Year Four Year Five

d. Phase-In/Phase-Out Time Period
Month

Waiver Year

Waiver Year: First Calendar Month
Phase-in/Phase-out begins
Phase-in/Phase-out ends

Appendix B: Participant Access and Eligibility
B-4: Eligibility Groups Served in the Waiver
a.

1. State Classification. The state is a (select one):
Section §1634 State
SSI Criteria State
209(b) State
2. Miller Trust State.
Indicate whether the state is a Miller Trust State (select one):
No
Yes

b. 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
Parents and Other Caretaker Relatives (42 CFR § 435.110)
Pregnant Women (42 CFR § 435.116)
Infants and Children under Age 19 (42 CFR § 435.118)
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:
Working individuals with disabilities who buy into Medicaid (BBA working disabled group as provided in
section §1902(a)(10)(A)(ii)(XIII)) of the Act)
Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in
§section 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 §section 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 §section 1902(e)(3) of the Act)

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:

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.
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
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:
Aged, blind and disabled individuals who meet requirements that are more restrictive than the SSI
program (42 CFR § 435.121)
Medically needy without spend down 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:
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:

Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (1 of 7)
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. 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:
Note: For the period beginning January 1, 2014 and extending through September 30, 2027 2019 (or other date as required
by law), the following instructions are mandatory. The following box should be checked for all waivers that furnish waiver
services to the 42 CFR § 435.217 group effective at any point during this time period.
Spousal impoverishment rules under section §1924 of the Act are used to determine the eligibility of individuals
with a community spouse for the special home and community-based waiver group. In the case of a participant
with a community spouse, the state uses spousal post-eligibility rules under section §1924 of the Act.
Complete Items B-5-e (if the selection for B-4-a-i is SSI State or §section 1634) or B-5-f (if the selection for B-4-a-i is
209b State) and Item B-5-g unless the state indicates that it also uses spousal post-eligibility rules for the time
periods before January 1, 2014 or after September 30, 20272019 (or other date as required by law).
Note: The following selections apply for the time periods before January 1, 2014 or after September 30, 20272019 (or
other date as required by law) (select one).
Spousal impoverishment rules under section §1924 of the Act are used to determine the eligibility of individuals
with a community spouse for the special home and community-based waiver group.
In the case of a participant with a community spouse, the state elects to (select one):
Use spousal post-eligibility rules under section §1924 of the Act.
(Complete Item B-5-c (209b State) and Item B-5-d)
Use regular post-eligibility rules under 42 CFR § 435.726 ((Section §1634 State/SSI Criteria State) or under §
435.735 (209b State)
(Complete Item B-5-c (209b State). Do not complete Item B-5-d)
Spousal impoverishment rules under section §1924 of the Act are not used to determine eligibility of individuals
with a community spouse for the special home and community-based waiver group. The state uses regular posteligibility rules for individuals with a community spouse.
(Complete Item B-5-c (209b State). Do not complete Item B-5-d)

Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (2 of 7)
Note: The following selections apply for the time periods before January 1, 2014 or after September 30, 2027 (or other date as
required by law)December 31, 2018.

b. Regular Post-Eligibility Treatment of Income: Section §1634 State and SSI Criteria State prior to January 1, 2014 or
after September 30. 2027 (or other date as required by law).
The state uses the post-eligibility rules at 42 CFR § 435.726. Payment for home and community-based waiver services is
reduced by the amount remaining after deducting the following allowances and expenses from the waiver participant's
income:
i. Allowance for the needs of the waiver participant (select one):
The following standard included under the state plan
Select one:
SSI standard
Optional state supplement standard
Medically needy income standard
The special income level for institutionalized persons
(select one):
300% of the SSI Federal Benefit Rate (FBR)
A percentage of the FBR, which is less than 300%
Specify the percentage:
A dollar amount which is less than 300%.
Specify dollar amount:
A percentage of the Federal poverty level
Specify percentage:
Other standard included under the state pPlan
Specify:

The following dollar amount
Specify dollar amount:

If this amount changes, this item will be revised.

The following formula is used to determine the needs allowance:
Specify:

Other
Specify:

ii. Allowance for the spouse only (select one):

Not Applicable (see instructions)
SSI standard
Optional state supplement standard
Medically needy income standard
The following dollar amount:
Specify dollar amount:

If this amount changes, this item will be revised.

The amount is determined using the following formula:
Specify:

iii. Allowance for the family (select one):
Not Applicable (see instructions)
AFDC need standard
Medically needy income standard
The following dollar amount:
Specify dollar amount:

The amount specified cannot exceed the higher of the need standard for a

family of the same size used to determine eligibility under the state's approved AFDC plan or the medically
needy income standard established under 42 CFR § 435.811 for a family of the same size. If this amount
changes, this item will be revised.
The amount is determined using the following formula:
Specify:

Other
Specify:

iv. Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified
in 42 §CFR § 435.726:
a. Health insurance premiums, deductibles and co-insurance charges
b. Necessary medical or remedial care expenses recognized under state law but not covered under the state's
Medicaid plan, subject to reasonable limits that the state may establish on the amounts of these expenses.
Select one:
Not Applicable (see instructions) Note: If the state protects the maximum amount for the waiver participant,
not applicable must be selected.
The state does not establish reasonable limits.
The state establishes the following reasonable limits:
Specify:

Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (3 of 7)
Note: The following selections apply for the time periods before January 1, 2014 or after September 30, 2027 (or other date as
required by law) December 31, 2018.
c. Regular Post-Eligibility Treatment of Income: 209(bB) State or §1634 State -– prior to January 1, 2014 through 2027
or after September 30, 2027 (or other date as required by law).

The state uses more restrictive eligibility requirements than SSI and uses the post-eligibility rules at 42 CFR § 435.735 for
individuals who do not have a spouse or have a spouse who is not a community spouse as specified in section §1924 of
the Act. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the
following amounts and expenses from the waiver participant's income:
i. Allowance for the needs of the waiver participant (select one):
The following standard included under the state plan
(select one):
The following standard under 42 CFR § 435.121
Specify:

Optional state supplement standard
Medically needy income standard
The special income level for institutionalized persons
(select one):
300% of the SSI Federal Benefit Rate (FBR)
A percentage of the FBR, which is less than 300%
Specify percentage:
A dollar amount which is less than 300%.
Specify dollar amount:
A percentage of the Federal poverty level
Specify percentage:
Other standard included under the state pPlan
Specify:

The following dollar amount
Specify dollar amount:

If this amount changes, this item will be revised.

The following formula is used to determine the needs allowance:
Specify:

Other
Specify:

ii. Allowance for the spouse only (select one):
Not Applicable
The state provides an allowance for a spouse who does not meet the definition of a community spouse in
section §1924 of the Act. Describe the circumstances under which this allowance is provided:
Specify:

Specify the amount of the allowance (select one):
The following standard under 42 CFR § 435.121
Specify:

Optional state supplement standard
Medically needy income standard
The following dollar amount:
Specify dollar amount:

If this amount changes, this item will be revised.

The amount is determined using the following formula:
Specify:

iii. Allowance for the family (select one):
Not Applicable (see instructions)
AFDC need standard
Medically needy income standard
The following dollar amount:
Specify dollar amount:

The amount specified cannot exceed the higher of the need standard for a

family of the same size used to determine eligibility under the sState's approved AFDC plan or the medically
needy income standard established under 42 CFR § 435.811 for a family of the same size. If this amount
changes, this item will be revised.
The amount is determined using the following formula:
Specify:

Other
Specify:

iv. Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified
in 42 §CFR § 435.73526:
a. Health insurance premiums, deductibles and co-insurance charges
b. Necessary medical or remedial care expenses recognized under state law but not covered under the state's
Medicaid plan, subject to reasonable limits that the state may establish on the amounts of these expenses.
Select one:
Not Applicable (see instructions)Note: If the state protects the maximum amount for the waiver participant,
not applicable must be selected.
The state does not establish reasonable limits.
The state establishes the following reasonable limits
Specify:

Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (4 of 7)
Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018 September 30, 2027 (or
other date as required by law).
d.
Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules prior to January 1, 2014 or after
September 30, 2027 (or other date as required by law)
The state uses the post-eligibility rules of § section 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 § section 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).
i. Allowance for the personal needs of the waiver participant
(select one):
SSI standard
Optional state supplement standard
Medically needy income standard
The special income level for institutionalized persons
A percentage of the Federal poverty level
Specify percentage:
The following dollar amount:
Specify dollar amount:

If this amount changes, this item will be revised

The following formula is used to determine the needs allowance:

Specify formula:

Other
Specify:

ii. If the allowance for the personal needs of a waiver participant with a community spouse is different from
the amount used for the individual's maintenance allowance under 42 CFR § 435.726 or 42 CFR §
435.735, explain why this amount is reasonable to meet the individual's maintenance needs in the
community.
Select one:
Allowance is the same
Allowance is different.
Explanation of difference:

iii. Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified
in 42 CFR § 435.726 or 42 CFR § 435.735:
a. Health insurance premiums, deductibles and co-insurance charges
b. Necessary medical or remedial care expenses recognized under state law but not covered under the state's
Medicaid plan, subject to reasonable limits that the state may establish on the amounts of these expenses.
Select one:
Not Applicable (see instructions) Note: If the state protects the maximum amount for the waiver participant,
not applicable must be selected.
The state does not establish reasonable limits.
The state uses the same reasonable limits as are used for regular (non-spousal) post-eligibility.

Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (5 of 7)
Note: The following selections apply for the five-year period beginning January 1, 2014 and extending through September 30, 2027
(or other date as required by law).
.
e.Regular Post-Eligibility Treatment of Income: Section §1634 State or SSI Criteria State -– January 1, 2014 through
2018 September 30, 2027 (or other date as required by law).
The state uses the post-eligibility rules at 42 CFR § 435.726 for individuals who do not have a spouse or have a spouse
who is not a community spouse as specified in §section 1924 of the Act. Payment for home and community-based waiver
services is reduced by the amount remaining after deducting the following allowances and expenses from the waiver
participant's income:
i.

Allowance for the needs of the waiver participant (select one):
The following standard included under the state plan
Select one:
SSI standard
Optional state supplement standard
Medically needy income standard
The special income level for institutionalized persons
(select one):
300% of the SSI Federal Benefit Rate (FBR)
A percentage of the FBR, which is less than 300%
Specify the percentage:
A dollar amount which is less than 300%.
Specify dollar amount:
A percentage of the Federal poverty level
Specify percentage:
Other standard included under the state pPlan
Specify:

The following dollar amount
Specify dollar amount:

If this amount changes, this item will be revised.

The following formula is used to determine the needs allowance:
Specify:

Other
Specify:

ii.

Allowance for the spouse only (select one):
Not Applicable
The state provides an allowance for a spouse who does not meet the definition of a community spouse in
section §1924 of the Act. Describe the circumstances under which this allowance is provided:
Specify:

Specify the amount of the allowance (select one):
SSI standard
Optional state supplement standard
Medically needy income standard
The following dollar amount:
Specify dollar amount:

If this amount changes, this item will be revised.

The amount is determined using the following formula:
Specify:

iii.

Allowance for the family (select one):
Not Applicable (see instructions)
AFDC need standard
Medically needy income standard
The following dollar amount:
Specify dollar amount:

The amount specified cannot exceed the higher of the need standard for a

family of the same size used to determine eligibility under the sState's approved AFDC plan or the medically
needy income standard established under 42 CFR § 435.811 for a family of the same size. If this amount
changes, this item will be revised.
The amount is determined using the following formula:
Specify:

Other
Specify:

iv.

Amounts for incurred medical or remedial care expenses not subject to payment by a third party,
specified in 42 §CFR § 435.726:
i. Health insurance premiums, deductibles and co-insurance charges
ii. Necessary medical or remedial care expenses recognized under state law but not covered under the state's
Medicaid plan, subject to reasonable limits that the state may establish on the amounts of these expenses.

Select one:
Not Applicable (see instructions) Note: If the state protects the maximum amount for the waiver participant,
not applicable must be selected.
The state does not establish reasonable limits.
The state establishes the following reasonable limits
Specify:

Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (6 of 7)
Note: The following selections apply for the five-year period beginning January 1, 2014 and extending through September 30, 2027
(or other date as required by law).
f. Regular Post-Eligibility Treatment of Income: 209(bB) State -– January 1, 2014 through 2018 September 30, 2027 (or
other date as required by law).
The state uses more restrictive eligibility requirements than SSI and uses the post-eligibility rules at 42 CFR § 435.735.
Payment for home and community-based waiver services is reduced by the amount remaining after deducting the
following amounts and expenses from the waiver participant's income:
i.

Allowance for the needs of the waiver participant (select one):
The following standard included under the state plan
(select one):
The following standard under 42 CFR § 435.121
Specify:

Optional state supplement standard
Medically needy income standard
The special income level for institutionalized persons
(select one):
300% of the SSI Federal Benefit Rate (FBR)
A percentage of the FBR, which is less than 300%
Specify percentage:
A dollar amount which is less than 300%.
Specify dollar amount:
A percentage of the Federal poverty level
Specify percentage:
Other standard included under the state pPlan
Specify:

The following dollar amount
Specify dollar amount:

If this amount changes, this item will be revised.

The following formula is used to determine the needs allowance:
Specify:

Other
Specify:

ii.

Allowance for the spouse only (select one):
Not Applicable (see instructions)
The following standard under 42 CFR § 435.121
Specify:

Optional state supplement standard
Medically needy income standard
The following dollar amount:
Specify dollar amount:

If this amount changes, this item will be revised.

The amount is determined using the following formula:
Specify:

iii.

Allowance for the family (select one):
Not Applicable (see instructions)
AFDC need standard
Medically needy income standard
The following dollar amount:
Specify dollar amount:

The amount specified cannot exceed the higher of the need standard for a

family of the same size used to determine eligibility under the sState's approved AFDC plan or the medically
needy income standard established under 42 CFR § 435.811 for a family of the same size. If this amount
changes, this item will be revised.
The amount is determined using the following formula:
Specify:

Other
Specify:

iv.

Amounts for incurred medical or remedial care expenses not subject to payment by a third party,
specified in 42 §CFR § 435.73526:
i. Health insurance premiums, deductibles and co-insurance charges
ii. Necessary medical or remedial care expenses recognized under state law but not covered under the state's
Medicaid plan, subject to reasonable limits that the state may establish on the amounts of these expenses.

Select one:
Not Applicable (see instructions)Note: If the state protects the maximum amount for the waiver participant,
not applicable must be selected.
The state does not establish reasonable limits.
The state establishes the following reasonable limits
Specify:

Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (7 of 7)
Note: The following selections apply for the five-year period beginning January 1, 2014 and extending through September 30, 2027
(or other date as required by law).
g. Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules -– January 1, 2014 through September 30,
20272018 (or other date as required by law).
The state uses the post-eligibility rules of section §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. 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).
i.

Allowance for the personal needs of the waiver participant

(select one):
SSI standard
Optional state supplement standard
Medically needy income standard
The special income level for institutionalized persons
A percentage of the Federal poverty level
Specify percentage:
The following dollar amount:
Specify dollar amount:

If this amount changes, this item will be revised

The following formula is used to determine the needs allowance:
Specify formula:

Other
Specify:

ii.

If the allowance for the personal needs of a waiver participant with a community spouse is
different from the amount used for the individual's maintenance allowance under 42 CFR §
435.726 or 42 CFR § 435.735, explain why this amount is reasonable to meet the individual's
maintenance needs in the community.

Select one:
Allowance is the same
Allowance is different.
Explanation of difference:

iii.

Amounts for incurred medical or remedial care expenses not subject to payment by a third party,
specified in 42 CFR § 435.726 or 42 CFR § 435.735 :
i. Health insurance premiums, deductibles and co-insurance charges
ii. Necessary medical or remedial care expenses recognized under state law but not covered under the state's
Medicaid plan, subject to reasonable limits that the state may establish on the amounts of these expenses.

Select one:
Not Applicable (see instructions) Note: If the state protects the maximum amount for the waiver participant,
not applicable must be selected.
The state does not establish reasonable limits.
The state uses the same reasonable limits as are used for regular (non-spousal) post-eligibility.

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.
a. 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:
i. 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:
ii. 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:

b. 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 government agency under contract with the Medicaid agency.
Specify the entity:

Other agency/entity
Specify:

c. 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:

d. 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.

e. 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 pPlan.
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.

f. 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:

g. 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:

h. 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:

i. 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):

j. 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:

Appendix B: Evaluation/Reevaluation of Level of Care
Quality Improvement: Level of Care
As a distinct component of the sState’s quality improvement strategy, provide information in the following fields to detail the sState’s
methods for discovery and remediation.
a. Methods for Discovery: Level of Care Assurance/Sub-assurances
The state demonstrates that it implements the processes and instrument(s) specified in its approved waiver for
evaluating/reevaluating an applicant's/waiver participant's level of care consistent with level of care provided in a
hospital, NF or ICF/IID.
i. Sub-Assurances:
a. 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 the sState will use to assess compliance with the statutory assurance
(or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

Performance Measure:

Data Source (Select one):

If 'Other' is selected, specify:

Responsible Party for data
collection/generation(check
each that applies):

Frequency of data
collection/generation(check
each that applies):

Sampling Approach(check
each that applies):

State Medicaid
Agency

Weekly

100% Review

Operating Agency

Monthly

Less than 100%
Review

Sub-State Entity

Quarterly

Representative
Sample
Confidence
Interval =

Other
Specify:

Annually

Stratified
Describe Group:

Continuously and
Ongoing

Other
Specify:

Other
Specify:

Add another Data Source for this performance measure

Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (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:

Add another Performance measure (button to prompt another performance measure)

b. 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 the sState will use to assess compliance with the statutory assurance
(or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

c. 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 the sState will use to assess compliance with the statutory assurance
(or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

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

b. Methods for Remediation/Fixing Individual Problems
i. Describe the sState’s method for addressing individual problems as they are discovered. Include information
regarding responsible parties and GENERAL methods for problem correction and the state’s method for analyzing
information from individual problems, identifying systemic deficiencies, and implementing remediation actions.
In addition, provide information on the methods used by the state to document these items.

ii. 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:

c. Timelines
When the sState does not have all elements of the qQuality iImprovement sStrategy in place, provide timelines to design
methods for discovery and remediation related to the assurance of lLevel of cCare that are currently non-operational.
No
Yes
Please provide a detailed strategy for assuring Level of Care, the specific timeline for implementing identified
strategies, and the parties responsible for its operation.

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:
i. informed of any feasible alternatives under the waiver; and
ii. given the choice of either institutional or home and community-based services.
a. 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).

b. 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.

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):

Appendix C: Participant Services
C-1: Summary of Services Covered (1 of 2)
a. 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/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through
the Medicaid agency or the operating agency (if applicable).
Service Type:
Service:
Alternate Service Title (if any):

HCBS Taxonomy:

Category 1:

Sub-Category 1:

Category 2:

Sub-Category 2:

Category 3:

Sub-Category 3:

Category 4:

Sub-Category 4:

Complete this part for a renewal application or a new waiver that replaces an existing waiver. Select one :
Service is included in approved waiver. There is no change in service specifications.
Service is included in approved waiver. The service specifications have been modified.
Service is not included in the approved waiver.
Service Definition (Scope):

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):
Participant-directed as specified in Appendix E
Provider managed
Remote/via Telehealth

Specify whether the service may be provided by (check each that applies):
Legally Responsible Person
Relative
Legal Guardian

Provider
Specifications:
Provider Category Provider Type Title

Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type:
Service Name:
Provider Category:

Provider Type:

Provider Qualifications
License (specify):

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications
Entity Responsible for Verification:

Frequency of Verification:

Appendix C: Participant Services
C-1: Summary of Services Covered (2 of 2)
b. Provision of Case Management Services to Waiver Participants. Indicate how case management is furnished to waiver
participants (select one):
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 §section 1915(i) of the Act (HCBS as a State Plan Option).
Complete item C-1-c.
As a Medicaid state plan service under §section 1915(g)(1) of the Act (Targeted Case Management).
Complete item C-1-c.
As an administrative activity. Complete item C-1-c.
As a primary care case management system service under a concurrent managed care authority. Complete
item C-1-c.
□

As a Medicaid state plan service under §section 1945 and/or §section 1945A of the Act (Health Homes
Comprehensive Care Management). Complete item C-1-c.

c. Delivery of Case Management Services. Specify the entity or entities that conduct case management functions on behalf
of waiver participants and the requirements for their training on the HCBS settings regulation and person-centered
planning requirements:

d. Remote/Telehealth Delivery of Waiver Services. Specify whether each waiver service that is specified in Appendix
C-1/C-3 can be delivered remotely/via telehealth.

** CHART OF SERVICES TO BE ADDED **
1.

Will any in-person visits be required?
o
o

2.

Yes
No

By checking each box below, the state assures that it will address the following when delivering the service remotely/via
telehealth.

** each bullet below to be a checkbox that states must select if they chose yes for any of the waiver services in the
chart):
□

The remote service will be delivered in a way that respects privacy of the individual especially in instances of
toileting, dressing, etc. Explain:

** text box to be added that states must complete if they choose yes to #1**
□

How the telehealth service delivery will facilitate community integration. Explain:

** text box to be added that states must complete if they choose yes to #1**

□

How the telehealth will ensure the successful delivery of services for individuals who need hands on
assistance/physical assistance, including whether the service can be rendered without someone who is physically
present or is separated from the individual. Explain:

** text box to be added that states must complete if they choose yes to #1**
□

How the state will support individuals who need assistance with using the technology required for telehealth
delivery of the service. Explain:

** text box to be added that states must complete if they choose yes to #1**
□

How the telehealth will ensure the health and safety of an individual. Explain:

** text box to be added that states must complete if they choose yes to #1**

Appendix C: Participant Services
C-2: General Service Specifications (1 of 3)
a. 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):

b. 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; and (d) the process for ensuring continuity of care for a waiver participant whose service provider was
added to the abuse registry. 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):

Appendix C: Participant Services
C-2: General Service Specifications (2 of 3)
Note: Required information from this page (Appendix C-2-c) is contained in response to C-5.

Appendix C: Participant Services
C-2: General Service Specifications (3 of 3)
d. 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 or regulations to care for another person and typically includes: (a) (e.g., 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 aAt the option of the sState 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 types of 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 the
method for determining that the amount of personal care or similar services provided by a legally responsible individual
is “extraordinary care” by a legally responsible individual, exceeding the ordinary care that would be provided to a person
without a disability or chronic illness of the same age, and which are necessary to assure the health and welfare of the
participant and avoid institutionalization; and how (c) the state policies to determine ensures that the provision of services
by a legally responsible individual is in the best interest of the participant; (d) the state processes to ensure that legally
responsible individuals who have decision-making authority over the selection of waiver service providers use substituted
judgement on behalf of the individual; (e) any limitations on the circumstances under which payment will be authorized
or the amount of personal care or similar services for which payment may be made; (f) any additional safeguards the state
implements when legally responsible individuals provide personal care or similar services; and, (gc) the procedures
controls that are used to implement required state oversight, such as employed to ensureing 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.

Self-directed
Agency-operated
e. 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 types of relatives/legal guardians to whom payment may be made, and the services for which payment may
be made, the specific circumstances under which payment is made, and the method of determining that such
circumstances apply. Also specify any limitations on the amount of services that may be furnished by a relative or legal
guardian, and any additional safeguards the state implements when relatives/legal guardians provide waiver services.
Specify the state policies to determine that that the provision of services by a relative/legal guardian is in the best
interests of the individual. When the relative/legal guardian has decision-making authority over the selection of
providers of waiver services, specify the state’s process for ensuring that the relative/legal guardian uses substituted
judgement on behalf of the individual. Specify the procedurescontrols 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.

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.

Other policy.
Specify:

f. 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:

g.State Option to Provide HCBS in Acute Care Hospitals in accordance with Section 1902(h)(1) of the Act. Specify
whether the state chooses the option to provide waiver HCBS in acute care hospitals. Select one:
o

No, the state does not choose the option to provide HCBS in acute care hospitals.

o

Yes, the state chooses the option to provide HCBS in acute care hospitals under the following conditions. By
checking the boxes below, the state assures:
□

The HCBS are provided to meet the needs of the individual that are not met through the provision of acute
care hospital services;

□

The HCBS are in addition to, and may not substitute for, the services the acute care hospital is obligated to
provide;

□

The HCBS must be identified in the individual’s person-centered service plan; and

□

The HCBS will be used to ensure smooth transitions between acute care setting and community-based
settings and to preserve the individual’s functional abilities.

And specify
(a) The 1915(c) HCBS in this waiver that can be provided by the 1915(c) HCBS provider that are not duplicative
of services available in the acute care hospital setting;
(b) How the 1915(c) HCBS will assist the individual in returning to the community; and
(c) Whether there is any difference from the typically billed rate for these HCBS provided during a hospitalization.
If yes, please specify the rate methodology in Appendix I-2-a.

**TEXT BOX TO BE ADDED HERE **

Appendix C: Participant Services

Quality Improvement: Qualified Providers

As a distinct component of the sState’s quality improvement strategy, provide information in the following fields to detail the sState’s
methods for discovery and remediation.
a. Methods for Discovery: Qualified Providers
The state demonstrates that it has designed and implemented an adequate system for assuring that all waiver services
are provided by qualified providers.
i. Sub-Assurances:
a. Sub-Assurance: The sState 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 the sState will use to assess compliance with the statutory assurance,
complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

Performance Measure:

Data Source (Select one):

If 'Other' is selected, specify:

Responsible Party for data
collection/generation(check
each that applies):

Frequency of data
collection/generation(check
each that applies):

Sampling Approach(check
each that applies):

State Medicaid
Agency

Weekly

100% Review

Operating Agency

Monthly

Less than 100%
Review

Sub-State Entity

Quarterly

Representative
Sample
Confidence
Interval =

Other
Specify:

Annually

Stratified
Describe Group:

Continuously and
Ongoing

Other
Specify:

Other
Specify:

Add another dData sSource for this performance measure

Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (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:

Add another pPerformance measure (button to prompt another performance measure)

b. Sub-Assurance: The sState monitors non-licensed/non-certified providers to assure adherence to
waiver requirements.
For each performance measure the sState will use to assess compliance with the statutory assurance,
complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

Performance Measure:

Data Source (Select one):

If 'Other' is selected, specify:

Responsible Party for data
collection/generation(check
each that applies):

Frequency of data
collection/generation(check
each that applies):

Sampling Approach(check
each that applies):

State Medicaid
Agency

Weekly

100% Review

Operating Agency

Monthly

Less than 100%
Review

Sub-State Entity

Quarterly

Representative
Sample
Confidence
Interval =

Other
Specify:

Annually

Stratified
Describe Group:

Continuously and
Ongoing

Other
Specify:

Other
Specify:

Add another dData sSource for this performance measure

Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (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:

Add another pPerformance measure (button to prompt another performance measure)

c. Sub-Assurance: The state implements its policies and procedures for verifying that training is provided
in accordance with state requirements and the approved waiver.
For each performance measure the sState will use to assess compliance with the statutory assurance,
complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

Performance Measure:

Data Source (Select one):

If 'Other' is selected, specify:

Responsible Party for data
collection/generation(check
each that applies):

Frequency of data
collection/generation(check
each that applies):

Sampling Approach(check
each that applies):

State Medicaid
Agency

Weekly

100% Review

Operating Agency

Monthly

Less than 100%
Review

Sub-State Entity

Quarterly

Representative
Sample
Confidence
Interval =

Other
Specify:

Annually

Stratified
Describe Group:

Continuously and
Ongoing

Other
Specify:

Other
Specify:

Add another dData sSource for this performance measure

Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (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:

Add another pPerformance measure (button to prompt another performance measure)

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

b. Methods for Remediation/Fixing Individual Problems
i. Describe the sState’s method for addressing individual problems as they are discovered. Include information
regarding responsible parties and GENERAL methods for problem correction and the state’s method for analyzing
information from individual problems, identifying systemic deficiencies, and implementing remediation actions.
In addition, provide information on the methods used by the state to document these items.

ii. 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:

c. Timelines
When the sState does not have all elements of the qQuality iImprovement sStrategy in place, provide timelines to design
methods for discovery and remediation related to the assurance of qQualified pProviders that are currently non-operational.
No
Yes
Please provide a detailed strategy for assuring qQualified pProviders, the specific timeline for implementing identified
strategies, and the parties responsible for its operation.

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

a. 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 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.

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.

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.

Other Type of Limit. The state employs another type of limit.
Describe the limit and furnish the information specified above.

Appendix C: Participant Services
C-5: Home and Community-Based Settings
Explain how residential and non-residential settings in this waiver comply with federal HCB Settings requirements at 42 CFR
§§ 441.301(c)(4)-(5) and associated CMS guidance. Include:
1. Description of the settings in which 1915(c) HCBS are received and how they meet federal HCB Settings
requirements, at the time of submission and in the future. (Specify and describe the types of settings in which waiver
services are received,)

**TEXT BOX TO BE ADDED HERE**

2. Description of the means by which the state Medicaid agency ascertains that all settings in which HCBS are received meet
federal HCB settings requirements, at the time of this submission and in the future as part of ongoing monitoring.
(Describe the process that the state will use to assess each setting including a detailed explanation of how the state will
perform on-going monitoring across residential and non-residential settings in which waiver HCBS are received.)

**TEXT BOX TO BE ADDED HERE**
2.3.
By checking each box below, the state assures that the process will ensure that each setting will meet each
requirement:
□ The setting is integrated in and supports full access of individuals receiving Medicaid HCBS to the greater
community, including opportunities to seek employment and work in competitive integrated settings , engage in
community life, control personal resources, and receive services in the community, to the same degree of access as
individuals not receiving Medicaid HCBS.
□

The setting is selected by the individual from among setting options including non-disability specific settings and an
option for a private unit in a residential setting. The setting options are identified and documented in the personcentered service plan and are based on the individual’s needs, preferences, and, for residential settings, resources
available for room and board. (see Appendix D-1-d-ii)

□

Ensures an individual’s rights of privacy, dignity and respect, and freedom from coercion and restraint.

□

Optimizes, but does not regiment, individual initiative, autonomy, and independence in making life choices,
including but not limited to, daily activities, physical environment, and with whom to interact.

□

Facilitates individual choice regarding services and supports, and who provides them.

□

Home and community-based settings do not include a nursing facility, an institution for mental diseases, an
intermediate care facility for individuals with intellectual disabilities, a hospital; or any other locations that have
qualities of an institutional setting.

Pprovider-owned or controlled residential settingin addition to meeting the above requirements, will meet the following
additional conditions):
□

The unit or dwelling is a specific physical place that can be owned, rented, or occupied under a legally
enforceable agreement by the individual receiving services, and the individual has, at a minimum, the same
responsibilities and protections from eviction that tenants have under the landlord/tenant law of the sState,
county, city, or other designated entity. For settings in which landlord tenant laws do not apply, the state must
ensure that a lease, residency agreement or other form of written agreement will be in place for each HCBS
participant, and that the document provides protections that address eviction processes and appeals comparable
to those provided under the jurisdiction’s landlord tenant law.

□

Each individual has privacy in their sleeping or living unit:
o

Units have entrance doors lockable by the individual:

o

Only appropriate staff have keys to unit entrance doors.

o

Individuals sharing units have a choice of roommates in that setting.

□

Individuals have the freedom to furnish and decorate their sleeping or living units within the lease or other
agreement.

□

Individuals have the freedom and support to control their own schedules and activities.

□

Individuals have access to food at any time.

□

Individuals are able to have visitors of their choosing at any time.

□

The setting is physically accessible to the individual.

□

Any modification of these additional conditions for provider-owned or controlled settings, under §
441.301(c)(4)(vi)(A) through (D), must be supported by a specific assessed need and justified in the personcentered service plan (see Appendix D-1-d-ii of this waiver application).

3. Description of the means by which the state Medicaid agency ascertains that all waiver settings meet federal HCB Setting
requirements, at the time of this submission and ongoing.
Note instructions at Module 1, Attachment #2, HCB Settings Waiver Transition Plan for description of settings that do not meet
requirements at the time of submission. Do not duplicate that information here.

Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (1 of 8)
State Participant-Centered Service Plan Title:

a. 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. Given the importance of the role
of the person-centered service plan in HCBS provision, the qualifications should include the training or
competency requirements for the HCBS settings criteria and person-centered service plan development. (Sselect
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:

Social Worker
Specify qualifications:

Other
Specify the individuals and their qualifications:

Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (2 of 8)
b. Service Plan Development Safeguards. Providers of HCBS for the individual, or those who have interest in or are
employed by a provider of HCBS; are not permitted to have responsibility for service plan development except, at the option
of the state, when providers are given responsibility to perform assessments and plans of care because such individuals are
the only willing and qualified entity in a geographic area, and the state devises conflict of interest protections. 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. Explain how the HCBS waiver service provider is the only
willing and qualified entity in a geographic area who can develop the service plan:

(Complete only if the second option is selected) The state has established the following safeguards to mitigate the
potential for conflict of interest in ensure that service plan development is conducted in the best interests of the
participant. SpecifyBy checking each box, the state attests to having a process in place to ensure:
□

□

□
□
□

Full disclosure to participants and assurance that participants are supported in exercising their right to free
choice of providers and are provided information about the full range of waiver services, not just the services
furnished by the entity that is responsible for the person-centered service plan development;
An opportunity for the participant to dispute the state’s assertion that there is not another entity or individual
that is not that individual’s provider to develop the person-centered service plan through a clear and
accessible alternative dispute resolution process;
Direct oversight of the process or periodic evaluation by a state agency;
Restriction of the entity that develops the person-centered service plan from providing services without the
direct approval of the state; and
Requirement for the agency that develops the person-centered service plan to administratively separate the
plan development function from the direct service provider functions.

Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (3 of 8)
c. 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.

Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (4 of 8)
d. i. Service Plan Development Process. In four pages or less, describe the process that is used to develop the participantcentered 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 and; (h) how the participant
engages in and/or directs the planning process; and (i) how the state documents consent of the person-centered service plan
from the waiver participant or their legal representative. 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):

ii. HCBS Settings Requirements for the Service Plan. By checking these boxes, the state assures that the following will be
included in the service plan:
□

The setting options are identified and documented in the person-centered service plan and are based on the individual’s
needs, preferences, and, for residential settings, resources available for room and board.

□

For provider owned or controlled settings, any modification of the additional conditions under 42 CFR §
441.301(c)(4)(vi)(A) through (D) must be supported by a specific assessed need and justified in the person-centered
service plan and the following will be documented in the person-centered service plan:
□

A specific and individualized assessed need for the modification.

□ Positive interventions and supports used prior to any modifications to the person-centered service plan.
□

Less intrusive methods of meeting the need that have been tried but did not work.

□ A clear description of the condition that is directly proportionate to the specific assessed need.
□ Regular collection and review of data to measure the ongoing effectiveness of the modification.
□ Established time limits for periodic reviews to determine if the modification is still necessary or can be
terminated.
□ Informed consent of the individual.
□ An assurance that interventions and supports will cause no harm to the individual.

Appendix D: Participant-Centered Planning and Service Delivery

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

Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (6 of 8)
f. 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.

Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (7 of 8)
g. 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):

Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (8 of 8)
h. Service Plan Review and Update. The service plan is subject to at least annual periodic review and update, when the
individual’s circumstances or needs change significantly, or at the request of the individual, 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:

i. 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:

Appendix D: Participant-Centered Planning and Service Delivery
D-2: Service Plan Implementation and Monitoring
a. Service Plan Implementation and Monitoring. Specify: (a) the entity (entities) responsible for monitoring the
implementation of the service plan, and participant health and welfare,; and adherence to the HCBS settings requirements
under 42 CFR §§ 441.301(c)(4)-(5); (b) the monitoring and follow-up method(s) that are used; and, (c) the frequency with
which monitoring is performed.

b. Monitoring Safeguards. Providers of HCBS for the individual, or those who have interest in or are employed by a provider
of HCBS; are not permitted to have responsibility for monitoring the implementation of the service plan except, at the option
of the state, when providers are given this responsibility because such individuals are the only willing and qualified entity in
a geographic area, and the state devises conflict of interest protections. Select one:
Entities and/or individuals that have responsibility to monitor service plan implementation, and
participant health and welfare, and adherence to the HCBS settings requirements 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, and adherence to the HCBS settings requirements may provide
other direct waiver services to the participant because they are the only the only willing and
qualified entity in a geographic area who can monitor service plan implementation. (Explain how the
HCBS waiver service provider is the only willing and qualified entity in a geographic area who can
monitor service plan implementation).

(Complete only if the second option is selected) The state has established the following safeguards to mitigate the
potential for conflict of interest in monitoring of service plan implementation, participant health and welfare, and
adherence to the HCBS settings requirements. ensure that monitoring is conducted in the best interests of the
participant. Specify:By checking each box, the state attests to having a process in place to ensure:
□

□

□
□
□

Full disclosure to participants and assurance that participants are supported in exercising their right to free choice
of providers and are provided information about the full range of waiver services, not just the services furnished
by the entity that is responsible for the person-centered service plan development;
An opportunity for the participant to dispute the state’s assertion that there is not another entity or individual that
is not that individual’s provider to develop the person-centered service plan through a clear and accessible
alternative dispute resolution process;
Direct oversight of the process or periodic evaluation by a state agency;
Restriction of the entity that develops the person-centered service plan from providing services without the direct
approval of the state; and
Requirement for the agency that develops the person-centered service plan to administratively separate the plan
development function from the direct service provider functions.

Appendix D: Participant-Centered Planning and Service Delivery
Quality Improvement: Service Plan
As a distinct component of the sState’s quality improvement strategy, provide information in the following fields to detail the sState’s
methods for discovery and remediation.
a. Methods for Discovery: Service Plan Assurance/Sub-assurances
The state demonstrates it has designed and implemented an effective system for reviewing the adequacy of service plans
for waiver participants.
i. Sub-Assurances:
a. Sub-assurance: Service plans address all participants’ assessed needs (including health and safety
risk factors) and personal and community integration goals, either by the provision of waiver services
or through other means.
Performance Measures
For each performance measure the sState will use to assess compliance with the statutory assurance

(or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

Performance Measure:

Data Source (Select one):

If 'Other' is selected, specify:

Responsible Party for data
collection/generation(check
each that applies):

Frequency of data
collection/generation(check
each that applies):

Sampling Approach(check
each that applies):

State Medicaid
Agency

Weekly

100% Review

Operating Agency

Monthly

Less than 100%
Review

Sub-State Entity

Quarterly

Representative
Sample
Confidence
Interval =

Other
Specify:

Annually

Stratified
Describe Group:

Continuously and
Ongoing

Other
Specify:

Other
Specify:

Add another Data Source for this performance measure

Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (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:

Add another Performance measure (button to prompt another performance measure)

b. Sub-assurance: Service plans are updated/revised at least annually, when the individual’s
circumstances or needs change significantly, or at the request of the individual. The State
monitors service plan development in accordance with its policies and procedures.
Performance Measures
For each performance measure the sState will use to assess compliance with the statutory assurance
(or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

Performance Measure:

Data Source (Select one):

If 'Other' is selected, specify:

Responsible Party for data
collection/generation(check
each that applies):

Frequency of data
collection/generation(check
each that applies):

Sampling Approach(check
each that applies):

State Medicaid
Agency

Weekly

100% Review

Operating Agency

Monthly

Less than 100%
Review

Sub-State Entity

Quarterly

Representative
Sample
Confidence
Interval =

Other
Specify:

Annually

Stratified
Describe Group:

Continuously and
Ongoing

Other
Specify:

Other
Specify:

Add another Data Source for this performance measure

Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (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:

Add another Performance measure (button to prompt another performance measure)

c. Sub-assurance: Services are delivered in accordance with the service plan, including the
type, scope, amount, duration, and frequency specified in the service planThe State
monitors service plan development in accordance with its policies and procedures.
Performance Measures
For each performance measure the sState will use to assess compliance with the statutory assurance
(or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

Performance Measure:

Data Source (Select one):

If 'Other' is selected, specify:

Responsible Party for data
collection/generation(check
each that applies):

Frequency of data
collection/generation(check
each that applies):

Sampling Approach(check
each that applies):

State Medicaid
Agency

Weekly

100% Review

Operating Agency

Monthly

Less than 100%
Review

Sub-State Entity

Quarterly

Representative
Sample
Confidence
Interval =

Other
Specify:

Annually

Stratified
Describe Group:

Continuously and
Ongoing

Other
Specify:

Other
Specify:

Add another Data Source for this performance measure

Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (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:

Add another Performance measure (button to prompt another performance measure)

d. Sub-assurance: Participants are afforded choice between/among waiver services and
providersThe State monitors service plan development in accordance with its policies and
procedures.
Performance Measures
For each performance measure the sState will use to assess compliance with the statutory assurance
(or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

Performance Measure:

Data Source (Select one):

If 'Other' is selected, specify:

Responsible Party for data
collection/generation(check
each that applies):

Frequency of data
collection/generation(check
each that applies):

Sampling Approach(check
each that applies):

State Medicaid
Agency

Weekly

100% Review

Operating Agency

Monthly

Less than 100%
Review

Sub-State Entity

Quarterly

Representative
Sample
Confidence
Interval =

Other
Specify:

Annually

Stratified
Describe Group:

Continuously and
Ongoing

Other
Specify:

Other
Specify:

Add another Data Source for this performance measure

Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (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:

Add another Performance measure (button to prompt another performance measure)

e. Sub-assurance: The sState monitors service plan development in accordance with its policies
and procedures.
Performance Measures
For each performance measure the sState will use to assess compliance with the statutory assurance
(or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

Performance Measure:

Data Source (Select one):

If 'Other' is selected, specify:

Responsible Party for data
collection/generation(check
each that applies):

Frequency of data
collection/generation(check
each that applies):

Sampling Approach(check
each that applies):

State Medicaid
Agency

Weekly

100% Review

Operating Agency

Monthly

Less than 100%
Review

Sub-State Entity

Quarterly

Representative
Sample
Confidence
Interval =

Other
Specify:

Annually

Stratified
Describe Group:

Continuously and
Ongoing

Other
Specify:

Other
Specify:

Add another Data Source for this performance measure

Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (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:

Add another Performance measure (button to prompt another performance measure)

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

b. Methods for Remediation/Fixing Individual Problems
i. Describe the sState’s method for addressing individual problems as they are discovered. Include information
regarding responsible parties and GENERAL methods for problem correction and the state’s method for analyzing
information from individual problems, identifying systemic deficiencies, and implementing remediation actions.
In addition, provide information on the methods used by the state to document these items.

ii. 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

Responsible Party(check each that applies):
Sub-State Entity

Frequency of data aggregation and analysis
(check each that applies):
Quarterly

Other
Specify:
Annually

Continuously and Ongoing
Other
Specify:

c. Timelines
When the sState does not have all elements of the qQuality iImprovement sStrategy in place, provide timelines to design
methods for discovery and remediation related to the assurance of Service Plans that are currently non-operational.
No
Yes
Please provide a detailed strategy for assuring Service Plans, the specific timeline for implementing identified
strategies, and the parties responsible for its operation.

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.
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.

Appendix E: Participant Direction of Services
E-1: Overview (1 of 13)
a. Description of Participant Direction. In no more than two pages, provide an overview of the opportunities for participant
direction in the waiver, including: (a) the nature of the opportunities afforded to participants; (b) how participants may take

advantage of these opportunities; (c) the entities that support individuals who direct their services and the supports that
they provide; and, (d) other relevant information about the waiver's approach to participant direction.

Appendix E: Participant Direction of Services
E-1: Overview (2 of 13)
b. Participant Direction Opportunities. Specify the participant direction opportunities that are available in the waiver.
Select one:
Participant: Employer Authority. As specified in Appendix E-2, Item a, the participant (or the participant's
representative) has decision-making authority over workers who provide waiver services. The participant may
function as the common law employer or the co-employer of workers. Supports and protections are available for
participants who exercise this authority.
Participant: Budget Authority. As specified in Appendix E-2, Item b, the participant (or the participant's
representative) has decision-making authority over a budget for waiver services. Supports and protections are
available for participants who have authority over a budget.
Both Authorities. The waiver provides for both participant direction opportunities as specified in Appendix E-2.
Supports and protections are available for participants who exercise these authorities.
c. Availability of Participant Direction by Type of Living Arrangement. Check each that applies:
Participant direction opportunities are available to participants who live in their own private residence or the
home of a family member.
Participant direction opportunities are available to individuals who reside in other living arrangements where
services (regardless of funding source) are furnished to fewer than four persons unrelated to the proprietor.
The participant direction opportunities are available to persons in the following other living arrangements
Specify these living arrangements:

Appendix E: Participant Direction of Services
E-1: Overview (3 of 13)
d. Election of Participant Direction. Election of participant direction is subject to the following policy (select one):

Waiver is designed to support only individuals who want to direct their services.
The waiver is designed to afford every participant (or the participant's representative) the opportunity to
elect to direct waiver services. Alternate service delivery methods are available for participants who
decide not to direct their services.
The waiver is designed to offer participants (or their representatives) the opportunity to direct some or
all of their services, subject to the following criteria specified by the state. Alternate service delivery
methods are available for participants who decide not to direct their services or do not meet the criteria.
Specify the criteria

Appendix E: Participant Direction of Services
E-1: Overview (4 of 13)
e. Information Furnished to Participant. Specify: (a) the information about participant direction opportunities (e.g., the
benefits of participant direction, participant responsibilities, and potential liabilities) that is provided to the participant (or
the participant's representative) to inform decision-making concerning the election of participant direction; (b) the entity or
entities responsible for furnishing this information; and, (c) how and when this information is provided on a timely basis.

Appendix E: Participant Direction of Services
E-1: Overview (5 of 13)
f. Participant Direction by a Representative. Specify the state's policy concerning the direction of waiver services by a
representative (select one):

The state does not provide for the direction of waiver services by a representative.
The state provides for the direction of waiver services by representatives.
Specify the representatives who may direct waiver services: (check each that applies):
Waiver services may be directed by a legal representative of the participant.
Waiver services may be directed by a non-legal representative freely chosen by an adult participant.
Specify the policies that apply regarding the direction of waiver services by participant-appointed
representatives, including safeguards to ensure that the representative functions in the best interest of the
participant:

Appendix E: Participant Direction of Services
E-1: Overview (6 of 13)
g. Participant-Directed Services. Specify the participant direction opportunity (or opportunities) available for each waiver
service that is specified as participant-directed in Appendix C-1/C-3.
Waiver Service Employer Authority Budget Authority

Appendix E: Participant Direction of Services
E-1: Overview (7 of 13)
h. Financial Management Services. Except in certain circumstances, financial management services are mandatory and
integral to participant direction. A governmental entity and/or another third-party entity must perform necessary financial
transactions on behalf of the waiver participant. Select one:

Yes. Financial Management Services are furnished through a third party entity. (Complete item E-1-i).
Specify whether governmental and/or private entities furnish these services. Check each that applies:
Governmental entities
Private entities
No. Financial Management Services are not furnished. Standard Medicaid payment mechanisms are used. Do
not complete Item E-1-i.

Appendix E: Participant Direction of Services
E-1: Overview (8 of 13)
i. Provision of Financial Management Services. Financial management services (FMS) may be furnished as a waiver
service or as an administrative activity. Select one:
FMS are covered as the waiver service specified in Appendix C-1/C-3
The waiver service entitled:
FMS are provided as an administrative activity.
Provide the following information
i. Types of Entities: Specify the types of entities that furnish FMS and the method of procuring these services:

ii. Payment for FMS. Specify how FMS entities are compensated for the administrative activities that they perform:

iii. Scope of FMS. Specify the scope of the supports that FMS entities provide (check each that applies):
Supports furnished when the participant is the employer of direct support workers:
Assist participant in verifying support worker citizenship status
Collect and process timesheets of support workers
Process payroll, withholding, filing and payment of applicable federal, state and local employmentrelated taxes and insurance
Other
Specify:

Supports furnished when the participant exercises budget authority:
Maintain a separate account for each participant's participant-directed budget
Track and report participant funds, disbursements and the balance of participant funds

Process and pay invoices for goods and services approved in the service plan
Provide participant with periodic reports of expenditures and the status of the participant-directed
budget
Other services and supports
Specify:

Additional functions/activities:
Execute and hold Medicaid provider agreements as authorized under a written agreement with the
Medicaid agency
Receive and disburse funds for the payment of participant-directed services under an agreement
with the Medicaid agency or operating agency
Provide other entities specified by the state with periodic reports of expenditures and the status of
the participant-directed budget
Other
Specify:

iv. Oversight of FMS Entities. Specify the methods that are employed to: (a) monitor and assess the performance of
FMS entities, including ensuring the integrity of the financial transactions that they perform; (b) the entity (or
entities) responsible for this monitoring; and, (c) how frequently performance is assessed.

Appendix E: Participant Direction of Services
E-1: Overview (9 of 13)
j. Information and Assistance in Support of Participant Direction. In addition to financial management services,
participant direction is facilitated when information and assistance are available to support participants in managing their
services. These supports may be furnished by one or more entities, provided that there is no duplication. Specify the
payment authority (or authorities) under which these supports are furnished and, where required, provide the additional
information requested (check each that applies):
Case Management Activity. Information and assistance in support of participant direction are furnished as an
element of Medicaid case management services.
Specify in detail the information and assistance that are furnished through case management for each participant
direction opportunity under the waiver:

Waiver Service Coverage.

Information and assistance in support of participant direction are provided through the following waiver service
coverage(s) specified in Appendix C-1/C-3 (check each that applies):
Participant-Directed Waiver Service

Information and Assistance Provided through this Waiver Service Coverage

Administrative Activity. Information and assistance in support of participant direction are furnished as an
administrative activity.
Specify (a) the types of entities that furnish these supports; (b) how the supports are procured and compensated; (c)
describe in detail the supports that are furnished for each participant direction opportunity under the waiver; (d) the
methods and frequency of assessing the performance of the entities that furnish these supports; and, (e) the entity or
entities responsible for assessing performance:

Appendix E: Participant Direction of Services
E-1: Overview (10 of 13)
k. Independent Advocacy (select one).

No. Arrangements have not been made for independent advocacy.
Yes. Independent advocacy is available to participants who direct their services.
Describe the nature of this independent advocacy and how participants may access this advocacy:

Appendix E: Participant Direction of Services
E-1: Overview (11 of 13)
l. Voluntary Termination of Participant Direction. Describe how the state accommodates a participant who voluntarily
terminates participant direction in order to receive services through an alternate service delivery method, including how
the state assures continuity of services and participant health and welfare during the transition from participant direction:

Appendix E: Participant Direction of Services
E-1: Overview (12 of 13)
m. Involuntary Termination of Participant Direction. Specify the circumstances when the state will involuntarily
terminate the use of participant direction and require the participant to receive provider-managed services instead,
including how continuity of services and participant health and welfare is assured during the transition.

Appendix E: Participant Direction of Services
E-1: Overview (13 of 13)
n. Goals for Participant Direction. In the following table, provide the state's goals for each year that the waiver is in effect
for the unduplicated number of waiver participants who are expected to elect each applicable participant direction
opportunity. Annually, the state will report to CMS the number of participants who elect to direct their waiver services.
Table E-1-n

Waiver
Year
Year 1
Year 2
Year 3
Year 4
Year 5

Employer Authority Only

Budget Authority Only or Budget Authority in Combination
with Employer Authority

Number of Participants

Number of Participants

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

a. Participant - Employer Authority Complete when the waiver offers the employer authority opportunity as indicated in
Item E-1-b:
i. Participant Employer Status. Specify the participant's employer status under the waiver. Select one or both:
Participant/Co-Employer. The participant (or the participant's representative) functions as the co-employer
(managing employer) of workers who provide waiver services. An agency is the common law employer of
participant-selected/recruited staff and performs necessary payroll and human resources functions. Supports
are available to assist the participant in conducting employer-related functions.
Specify the types of agencies (a.k.a., agencies with choice) that serve as co-employers of participant-selected
staff:

Participant/Common Law Employer. The participant (or the participant's representative) is the common law
employer of workers who provide waiver services. An IRS-approved Fiscal/Employer Agent functions as the
participant's agent in performing payroll and other employer responsibilities that are required by federal and
state law. Supports are available to assist the participant in conducting employer-related functions.
ii. Participant Decision Making Authority. The participant (or the participant's representative) has decision making
authority over workers who provide waiver services. Select one or more decision making authorities that
participants exercise:
Recruit staff
Refer staff to agency for hiring (co-employer)
Select staff from worker registry
Hire staff common law employer
Verify staff qualifications
Obtain criminal history and/or background investigation of staff
Specify how the costs of such investigations are compensated:

Specify additional staff qualifications based on participant needs and preferences so long as such
qualifications are consistent with the qualifications specified in Appendix C-1/C-3.
Specify the state's method to conduct background checks if it varies from Appendix C-2-a:

Determine staff duties consistent with the service specifications in Appendix C-1/C-3.
Determine staff wages and benefits subject to state limits
Schedule staff
Orient and instruct staff in duties
Supervise staff
Evaluate staff performance
Verify time worked by staff and approve time sheets
Discharge staff (common law employer)
Discharge staff from providing services (co-employer)
Other
Specify:

Appendix E: Participant Direction of Services
E-2: Opportunities for Participant-Direction (2 of 6)
b. Participant - Budget Authority Complete when the waiver offers the budget authority opportunity as indicated in Item E1-b:
i. Participant Decision Making Authority. When the participant has budget authority, indicate the decision-making
authority that the participant may exercise over the budget. Select one or more:
Reallocate funds among services included in the budget
Determine the amount paid for services within the state's established limits
Substitute service providers
Schedule the provision of services
Specify additional service provider qualifications consistent with the qualifications specified in
Appendix C-1/C-3
Specify how services are provided, consistent with the service specifications contained in Appendix C1/C-3
Identify service providers and refer for provider enrollment
Authorize payment for waiver goods and services
Review and approve provider invoices for services rendered

Other
Specify:

Appendix E: Participant Direction of Services
E-2: Opportunities for Participant-Direction (3 of 6)
b. Participant - Budget Authority
ii. Participant-Directed Budget Describe in detail the method(s) that are used to establish the amount of the
participant-directed budget for waiver goods and services over which the participant has authority, including how
the method makes use of reliable cost estimating information and is applied consistently to each participant.
Information about these method(s) must be made publicly available.

Appendix E: Participant Direction of Services
E-2: Opportunities for Participant-Direction (4 of 6)
b. Participant - Budget Authority
iii. Informing Participant of Budget Amount. Describe how the state informs each participant of the amount of the
participant-directed budget and the procedures by which the participant may request an adjustment in the budget
amount.

Appendix E: Participant Direction of Services
E-2: Opportunities for Participant-Direction (5 of 6)
b. Participant - Budget Authority
iv. Participant Exercise of Budget Flexibility. Select one:

Modifications to the participant directed budget must be preceded by a change in the service plan.
The participant has the authority to modify the services included in the participant directed
budget without prior approval.
Specify how changes in the participant-directed budget are documented, including updating the service plan.
When prior review of changes is required in certain circumstances, describe the circumstances and specify the
entity that reviews the proposed change:

Appendix E: Participant Direction of Services
E-2: Opportunities for Participant-Direction (6 of 6)
b. Participant - Budget Authority
v. Expenditure Safeguards. Describe the safeguards that have been established for the timely prevention of the
premature depletion of the participant-directed budget or to address potential service delivery problems that may be
associated with budget underutilization and the entity (or entities) responsible for implementing these safeguards:

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.

Appendix F: Participant-Rights
Appendix F-2: Additional Dispute Resolution Process
a. 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
b. 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.

Appendix F: Participant-Rights
Appendix F-3: State Grievance/Complaint System
a. 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
b. Operational Responsibility. Specify the state agency that is responsible for the operation of the grievance/complaint
system:

c. 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).

Appendix G: Participant Safeguards
Appendix G-1: Response to Critical Events or Incidents
a. 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:
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.

b. 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).

c. 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.

d. 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.

e. 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.

Appendix G: Participant Safeguards
Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (1 of
3)
a. Use of Restraints. (Select one): (For waiver actions submitted before March 2014, responses in Appendix G-2-a will
display information for both restraints and seclusion. For most waiver actions submitted after March 2014, responses
regarding seclusion appear in Appendix G-2-c.)
The state does not permit or prohibits the use of restraints
Specify the state agency (or agencies) responsible for detecting the unauthorized use of restraints and how this
oversight is conducted and its frequency:

The use of restraints is permitted during the course of the delivery of waiver services. Complete Items G-2-a-i
and G-2-a-ii.
i. Safeguards Concerning the Use of Restraints. 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). State laws, regulations, and policies that are referenced are available to CMS upon request through
the Medicaid agency or the operating agency (if applicable).

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

Appendix G: Participant Safeguards
Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (2 of
3)

b. 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:

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.
i. 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.

ii. 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:

Appendix G: Participant Safeguards
Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (3 of
3)
c. Use of Seclusion. (Select one): (This section will be blank for waivers submitted before Appendix G-2-c was added to
WMS in March 2014, and responses for seclusion will display in Appendix G-2-a combined with information on
restraints.)
The state does not permit or prohibits the use of seclusion
Specify the state agency (or agencies) responsible for detecting the unauthorized use of seclusion and how this
oversight is conducted and its frequency:

The use of seclusion is permitted during the course of the delivery of waiver services. Complete Items G-2-c-i
and G-2-c-ii.
i. Safeguards Concerning the Use of Seclusion. Specify the safeguards that the state has established
concerning the use of each type of 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).

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

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.
a. Applicability. Select one:
No. This Appendix is not applicable (do not complete the remaining items)
Yes. This Appendix applies (complete the remaining items)
b. Medication Management and Follow-Up
i. 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.

ii. 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.

Appendix G: Participant Safeguards
Appendix G-3: Medication Management and Administration (2 of 2)
c. Medication Administration by Waiver Providers
i. 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)
ii. 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).

iii. 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:

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

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

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:

iv. 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.

Appendix G: Participant Safeguards
Quality Improvement: Health and Welfare
As a distinct component of the sState’s quality improvement strategy, provide information in the following fields to detail the sState’s
methods for discovery and remediation.
a. Methods for Discovery: Health and Welfare

The state demonstrates it has designed and implemented an effective system for assuring waiver participant health and
welfare. (For waiver actions submitted before June 1, 2014, this assurance read "The State, on an ongoing basis,
identifies, addresses, and seeks to prevent the occurrence of abuse, neglect and exploitation.")
i. Sub-Assurances:
a. Sub-assurance: The state demonstrates on an ongoing basis that it identifies, addresses and seeks to
prevent instances of abuse, neglect, exploitation and unexplained death. (Performance measures in this
sub-assurance include all Appendix G performance measures for waiver actions submitted before June 1,
2014.)
Performance Measures
For each performance measure the sState will use to assess compliance with the statutory assurance
(or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

Performance Measure:

Data Source (Select one):

If 'Other' is selected, specify:

Responsible Party for data
collection/generation(check
each that applies):

Frequency of data
collection/generation(check
each that applies):

Sampling Approach(check
each that applies):

State Medicaid
Agency

Weekly

100% Review

Operating Agency

Monthly

Less than 100%
Review

Sub-State Entity

Quarterly

Representative
Sample
Confidence
Interval =

Other
Specify:

Annually

Stratified
Describe Group:

Continuously and
Ongoing

Other
Specify:

Other
Specify:

Add another Data Source for this performance measure

Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (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:

Add another Performance measure (button to prompt another performance measure)

b. Sub-assurance: The state demonstrates that an incident management system is in place that effectively
resolves those incidents and prevents further similar incidents to the extent possible.
Performance Measures
For each performance measure the sState will use to assess compliance with the statutory assurance
(or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

Performance Measure:

Data Source (Select one):

If 'Other' is selected, specify:

Responsible Party for data
collection/generation(check
each that applies):

Frequency of data
collection/generation(check
each that applies):

Sampling Approach(check
each that applies):

State Medicaid
Agency

Weekly

100% Review

Operating Agency

Monthly

Less than 100%
Review

Sub-State Entity

Quarterly

Representative
Sample
Confidence
Interval =

Other
Specify:

Annually

Stratified
Describe Group:

Continuously and
Ongoing

Other
Specify:

Other
Specify:

Add another Data Source for this performance measure

Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (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:

Add another Performance measure (button to prompt another performance measure)

c. Sub-assurance: The state policies and procedures for the use or prohibition of restrictive interventions
(including restraints and seclusion) are followed.
Performance Measures
For each performance measure the sState will use to assess compliance with the statutory assurance
(or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

Performance Measure:

Data Source (Select one):

If 'Other' is selected, specify:

Responsible Party for data
collection/generation(check
each that applies):

Frequency of data
collection/generation(check
each that applies):

Sampling Approach(check
each that applies):

State Medicaid
Agency

Weekly

100% Review

Operating Agency

Monthly

Less than 100%
Review

Sub-State Entity

Quarterly

Representative
Sample
Confidence
Interval =

Other
Specify:

Annually

Stratified
Describe Group:

Continuously and
Ongoing

Other
Specify:

Other
Specify:

Add another Data Source for this performance measure

Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (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:

Add another Performance measure (button to prompt another performance measure)

d. Sub-assurance: The state establishes overall health care standards and monitors those standards based
on the responsibility of the service provider as stated in the approved waiver.
Performance Measures
For each performance measure the sState will use to assess compliance with the statutory assurance
(or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

Performance Measure:

Data Source (Select one):

If 'Other' is selected, specify:

Responsible Party for data
collection/generation(check
each that applies):

Frequency of data
collection/generation(check
each that applies):

Sampling Approach(check
each that applies):

State Medicaid
Agency

Weekly

100% Review

Operating Agency

Monthly

Less than 100%
Review

Sub-State Entity

Quarterly

Representative
Sample
Confidence
Interval =

Other
Specify:

Annually

Stratified
Describe Group:

Continuously and
Ongoing

Other
Specify:

Other
Specify:

Add another Data Source for this performance measure

Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (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:

Add another Performance measure (button to prompt another performance measure)

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

b. Methods for Remediation/Fixing Individual Problems
i. Describe the sState’s method for addressing individual problems as they are discovered. Include information
regarding responsible parties and GENERAL methods for problem correction and the state’s method for analyzing
information from individual problems, identifying systemic deficiencies, and implementing remediation actions.
In addition, provide information on the methods used by the state to document these items.

ii. 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:

c. Timelines
When the sState does not have all elements of the qQuality iImprovement sStrategy in place, provide timelines to design
methods for discovery and remediation related to the assurance of hHealth and wWelfare that are currently nonoperational.
No
Yes
Please provide a detailed strategy for assuring Health and Welfare, the specific timeline for implementing identified
strategies, and the parties responsible for its operation.

Appendix H: Quality Improvement Strategy (1 of 3)
Under Section §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 iImprovement 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 qQuality iImprovement sStrategy 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 qQuality iImprovement sStrategy 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 qQuality iImprovement sStrategy.
Quality Improvement Strategy: Minimum Components
The qQuality iImprovement sStrategy (QIS) 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 QIS 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; and

■

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 OIS and revise it as necessary and appropriate.
If the state's QIS 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 QISQuality 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 QIS 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 QISQuality Improvement Strategy. In instances when the QIS spans more than one waiver, the state must be
able to stratify information that is related to each approved waiver program. Unless the state has requested and received approval
from CMS for the consolidation of multiple waivers for the purpose of reporting, then the state must stratify information that is
related to each approved waiver program, i.e., employ a representative sample for each waiver.

Appendix H: Quality Improvement Strategy (2 of 3)
H-1: Systems Improvement
a. System Improvements
i. 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.

ii. 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:

b. System Design Changes
i. 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.

ii. Describe the process to periodically evaluate, as appropriate, the qQuality iImprovement sStrategy.

Appendix H: Quality Improvement Strategy (3 of 3)
H-2: Use of a Patient Experience of Care/Quality of Life Survey
a. Specify whether the state has deployed a patient experience of care or quality of life survey for its HCBS population
in the last 12 months (Select one):
No
Yes (Complete item H.2b)
b. Specify the type of survey tool the state uses:
HCBS CAHPS Survey :
NCI Survey :
NCI AD Survey :
Other (Please provide a description of the survey tool used):

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).

Appendix I: Financial Accountability
Quality Improvement: Financial Accountability
As a distinct component of the sState’s quality improvement strategy, provide information in the following fields to detail the
sState’s methods for discovery and remediation.
a. Methods for Discovery: Financial Accountability Assurance:
The sState must demonstrate that it has designed and implemented an adequate system for ensuring financial
accountability of the waiver program. (For waiver actions submitted before June 1, 2014, this assurance read "State
financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology
specified in the approved waiver.")
i. Sub-Assurances:
a. Sub-assurance: The sState provides evidence that claims are coded and paid for in accordance with
the reimbursement methodology specified in the approved waiver and only for services rendered.
(Performance measures in this sub-assurance include all Appendix I performance measures for waiver
actions submitted before June 1, 2014.)
Performance Measures
For each performance measure the sState will use to assess compliance with the statutory assurance
(or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

Performance Measure:

Data Source (Select one):

If 'Other' is selected, specify:

Responsible Party for data
collection/generation(check
each that applies):

Frequency of data
collection/generation(check
each that applies):

Sampling Approach(check
each that applies):

State Medicaid
Agency

Weekly

100% Review

Operating Agency

Monthly

Less than 100%
Review

Sub-State Entity

Quarterly

Representative
Sample
Confidence
Interval =

Other
Specify:

Annually

Stratified
Describe Group:

Continuously and
Ongoing

Other
Specify:

Other
Specify:

Add another Data Source for this performance measure

Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (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:

Add another Performance measure (button to prompt another performance measure)

b. Sub-assurance: The state provides evidence that rates remain consistent with the approved rate
methodology throughout the five year waiver cycle.
Performance Measures
For each performance measure the sState will use to assess compliance with the statutory assurance
(or sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the sState 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.

Performance Measure:

Data Source (Select one):

If 'Other' is selected, specify:

Responsible Party for data
collection/generation(check
each that applies):

Frequency of data
collection/generation(check
each that applies):

Sampling Approach(check
each that applies):

State Medicaid
Agency

Weekly

100% Review

Operating Agency

Monthly

Less than 100%
Review

Sub-State Entity

Quarterly

Representative
Sample
Confidence
Interval =

Other
Specify:

Annually

Stratified
Describe Group:

Continuously and
Ongoing

Other
Specify:

Other
Specify:

Add another Data Source for this performance measure

Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (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:

Add another Performance measure (button to prompt another performance measure)

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

b. Methods for Remediation/Fixing Individual Problems
i. Describe the sStat’es method for addressing individual problems as they are discovered. Include information
regarding responsible parties and GENERAL methods for problem correction and the state’s method for analyzing
information from individual problems, identifying systemic deficiencies, and implementing remediation actions.
In addition, provide information on the methods used by the state to document these items.

ii. 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:

c. Timelines
When the sState does not have all elements of the qQuality iImprovement sStrategy 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
Please provide a detailed strategy for assuring Financial Accountability, the specific timeline for implementing
identified strategies, and the parties responsible for its operation.

Appendix I: Financial Accountability
I-2: Rates, Billing and Claims (1 of 3)
a. 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).

b. 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:

Appendix I: Financial Accountability
I-2: Rates, Billing and Claims (2 of 3)
c. 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.)

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.)

Appendix I: Financial Accountability
I-2: Rates, Billing and Claims (3 of 3)
d. 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:

e. 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)
a. 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:

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:

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:

Appendix I: Financial Accountability
I-3: Payment (2 of 7)
b. 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:

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.

Appendix I: Financial Accountability
I-3: Payment (3 of 7)
c. 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 nonFederal 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.

Appendix I: Financial Accountability
I-3: Payment (4 of 7)
d. 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:

Appendix I: Financial Accountability
I-3: Payment (5 of 7)
e. 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:

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:

Appendix I: Financial Accountability
I-3: Payment (6 of 7)
f. 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 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.

Appendix I: Financial Accountability
I-3: Payment (7 of 7)
g. Additional Payment Arrangements
i. 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.

ii. 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:

iii. Contracts with MCOs, PIHPs or PAHPs.
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 §section 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 § section 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.

This waiver is a part of a concurrent § section 1915(b)/§ section 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 §section 1915(b) waiver specifies the types of health plans that are
used and how payments to these plans are made.
This waiver is a part of a concurrent section 1115/ section 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 section 1115 waiver specifies the types of health plans that are used
and how payments to these plans are made.
If the state uses more than one of the above contract authorities for the delivery of waiver services, please
select this option.
In the textbox below, indicate the contract authorities. In addition, if the state contracts with MCOs, PIHPs,
or PAHPs under the provisions of §section 1915(a)(1) of the Act to furnish waiver 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 §section 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.

Appendix I: Financial Accountability
I-4: Non-Federal Matching Funds (1 of 3)
a. 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 Aagency
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-2c:

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:

Appendix I: Financial Accountability
I-4: Non-Federal Matching Funds (2 of 3)
b. 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:
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:

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:

Appendix I: Financial Accountability
I-4: Non-Federal Matching Funds (3 of 3)
c. 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:
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:

Appendix I: Financial Accountability

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

a. 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.
b. 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:

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:

Appendix I: Financial Accountability
I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (1 of 5)
a. 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.
i. 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:

Appendix I: Financial Accountability
I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (2 of 5)
a. Co-Payment Requirements.
ii. Participants Subject to Co-pay Charges for Waiver Services.
Specify the groups of waiver participants who are subject to charges for the waiver services specified in Item I-7-aiii and the groups for whom such charges are excluded.

Appendix I: Financial Accountability
I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (3 of 5)
a. Co-Payment Requirements.
iii. Amount of Co-Pay Charges for Waiver Services.
The following table lists the waiver services defined in C-1/C-3 for which a charge is made, the amount of the
charge, and the basis for determining the charge.
Waiver Service

Charge
Amount:

Basis:

Appendix I: Financial Accountability
I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (4 of 5)
a. Co-Payment Requirements.
iv. Cumulative Maximum Charges.
Indicate whether there is a cumulative maximum amount for all co-payment charges to a waiver participant (select
one):

There is no cumulative maximum for all deductible, coinsurance or co-payment charges to a waiver
participant.
There is a cumulative maximum for all deductible, coinsurance or co-payment charges to a waiver
participant.
Specify the cumulative maximum and the time period to which the maximum applies:

Appendix I: Financial Accountability
I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (5 of 5)
b. 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:

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-2-d Estimate of Factor D tables. Col. 2 fields will be populated ONLY when the Estimate of Factor D
tables in J-2-d have been completed.
Level(s) of Care: Hospital, Nursing Facility, ICF/IID
Col. 1 Col. 2
Year Factor D

Col. 3
Factor D'

Col. 4
Total: D+D'

Col. 5
Factor G

Col. 6
Factor G'

Col. 7
Col. 8
Total: G+G' Difference (Col 7 less Column4)

1
2
3
4
5

Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (1 of 9)
a. 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:

Waiver Year

Total
Unduplicated
Number of
Participants
(from Item B3-a)

Table: J-2-a: Unduplicated Participants
Distribution of Unduplicated Participants by Level of Care (if applicable)
Level of Care:
Level of Care:
Level of Care:
Hospital
Nursing Facility
ICF/IID

Year 1
Year 2
Year 3
Year 4
Year 5

Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (2 of 9)
b. 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.

Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (3 of 9)
c. Derivation of Estimates for Each Factor. Provide a narrative description for the derivation of the estimates of the
following factors.
i. Factor D Derivation. The estimates of Factor D for each waiver year are located in Item J-2-d. The basis and
methodology for these estimates is as follows:

ii. 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:

iii. 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:

iv. 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:

Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (4 of 9)
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.
Waiver Services

Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (5 of 9)
d. Estimate of Factor D.
ii. Concurrent section§ 1915(b)/§section 1915(c) Waivers, or other authorities utilizing capitated arrangements (i.e.,
1915(a), 1932(a), Section 1937). 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. If applicable, check the
capitation box next to that service. 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
Waiver
Service/
Component

Capitation

Unit

# Users

Avg. Units Per User

Avg. Cost/ Unit

Component Total
Cost
Cost

Total:

GRAND TOTAL:
Total: Services included in capitation:
Total: Services not included in capitation:
Total Estimated Unduplicated Participants:
Factor D (Divide total by number of participants):
Services included in capitation:
Services not included in capitation:
Average Length of Stay on the Waiver:

Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (6 of 9)
d. Estimate of Factor D.
ii. Concurrent section §1915(b)/§section 1915(c) Waivers, or other concurrent managed care authorities utilizing
capitated payment arrangements. 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. If applicable, check the
capitation box next to that service. 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
Waiver
Service/
Component

Capitation

Unit

# Users

Total:

GRAND TOTAL:
Total: Services included in capitation:
Total: Services not included in capitation:
Total Estimated Unduplicated Participants:
Factor D (Divide total by number of participants):
Services included in capitation:
Services not included in capitation:
Average Length of Stay on the Waiver:

Avg. Units Per User

Avg. Cost/ Unit

Component Total
Cost
Cost

Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (7 of 9)
d. Estimate of Factor D.
ii. Concurrent section §1915(b)/§section 1915(c) Waivers, or other concurrent managed care authorities utilizing
capitated payment arrangements. 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. If applicable, check the
capitation box next to that service. 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
Waiver
Service/
Component

Capitation

Unit

# Users

Total:

GRAND TOTAL:
Total: Services included in capitation:
Total: Services not included in capitation:
Total Estimated Unduplicated Participants:
Factor D (Divide total by number of participants):
Services included in capitation:
Services not included in capitation:
Average Length of Stay on the Waiver:

Avg. Units Per User

Avg. Cost/ Unit

Component Total
Cost
Cost

Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (8 of 9)
d. Estimate of Factor D.
ii. Concurrent section §1915(b)/§section 1915(c) Waivers, or other concurrent managed care authorities utilizing
capitated payment arrangements. 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. If applicable, check the
capitation box next to that service. 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 4
Waiver
Service/
Component

Capitation

Unit

# Users

Avg. Units Per User

Avg. Cost/ Unit

Component Total
Cost
Cost

Total:

GRAND TOTAL:
Total: Services included in capitation:
Total: Services not included in capitation:
Total Estimated Unduplicated Participants:
Factor D (Divide total by number of participants):
Services included in capitation:
Services not included in capitation:
Average Length of Stay on the Waiver:

Appendix J: Cost Neutrality Demonstration
J-2: Derivation of Estimates (9 of 9)
d. Estimate of Factor D.
ii. Concurrent section §1915(b)/§section 1915(c) Waivers, or other concurrent managed care authorities utilizing
capitated payment arrangements. 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. If applicable, check the
capitation box next to that service. 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 5
Waiver
Service/
Component

Capitation

Unit

# Users

Total:

GRAND TOTAL:
Total: Services included in capitation:
Total: Services not included in capitation:
Total Estimated Unduplicated Participants:
Factor D (Divide total by number of participants):
Services included in capitation:
Services not included in capitation:
Average Length of Stay on the Waiver:

Avg. Units Per User

Avg. Cost/ Unit

Component Total
Cost
Cost