Crosswalk: Application

Del

Appendix A-7 - Distribution of Waiver Operational and
Administrative Functions. In the chart, item titled "Level of
Care Evaluation"
Appendix A-7: Distribution of Waiver Operational and
Administrative Functions

In the chart, revised "Level of eare
Rev
Evaluation" to "Level of care waiver
eligibility evaluation"
Added the following note - "In 1915(c)
Add
waivers that include the 42 CFR § 435.217
special home and community-based
services waiver eligibility group, 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. Nongovernmental 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 levelof-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

Burden
Change

Reason
for
Change

Type of
Change

2023
(new
version)

2020
(old
version)

Removed this section (attachment)
Attachment #2: Home and Community-Based Waiver
Settings Transition Plan where states specified their process
to bring the waiver into compliance with federal home and
community-based (HCB) settings requirements at 42 CFR
441.301(c)(4)-(5), and associated CMS guidance.

This section is no longer needed. No
States provide information
regarding compliance with the
settings requirements in
Appendix C-5.

Minor/technical edit.

No

To clarify that in 1915(c) waivers No.
that include the 42 CFR § 435.217
special home and communitybased services waiver eligibility
group, Medicaid eligibility
determinations can only be
performed by the SMA or a
government agency delegated by
the SMA in accordance with 42
CFR § 431.10.

Burden
Change

Reason
for
Change

Type of
Change

2023
(new
version)

2020
(old
version)

Appendix B-4: financial eligibility, low income families with Appendix B-4, updated financial
Del, Add
children as provided in 1931 of the Act
eligibility. Appendix B-4-b, Medicaid
Eligiblity Groups Served in the Waiver,
removed the eligibility group "low
income families with children as provided
in 1931 of the Act." Added three groups:
Parents and Other Caretaker Relatives (42
CFR 435.110), Pregnant Women (42 CFR
435.116), and Infants and Children under
Age 19 (42 CFR 435.118).

After the enactment of the
No
Affordable Care Act, the
regulations were updated to
separate out the populations that
are covered under the "low

Main Module 6. Additional Requirements Item F: "FFP also Removed this language.
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,"

Del

technical update

No

Appendix B-5: Post Eligibility Treatment of Income

Rev

technical updates

No

Revised the end date throughout from
2019 to 2027 as well as adding "or other
date as required by law." Also updated,
corrected and clarified citations.

income families with children
as provided in §1931 of the
Act”, specifically the
populations of Parents and
Other Caretaker Relatives (42
CFR 435.110), Pregnant
Women (42 CFR 435.116), and
Infants and Children under Age
19 (42 CFR 435.118). These
three groups describe more
accurately the populations
covered as “low income
families with children as
provided in §1931 of the Act.”

Revised the 3rd radio button to replace
"government agency" with "entity."

Rev

Appendix C-1-c: Delivery of Case Management Services.

Added "and the requirements for their
Add
training on the HCBS settings regulation
and person-centered plannng
requirements" to the existing language.
It now reads "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:"

Burden
Change

Reason
for
Change

Type of
Change

2023
(new
version)

2020
(old
version)

B-6-b: Responsibility for Performing Evaluations and
Reevaluations

To reflect that the option for this No
function to be performed by an
entity under contract with the
SMA. Note: As noted in the
1915(c) waiver instructions and
technical guide, in 1915(c)
waivers that include the 42 CFR §
435.217 special home and
community-based services waiver
eligibility group, 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. Nongovernmental entities can
support administrative functions
of the eligibility determination
process that do not require
discretion
for with
example, Yes. Add 1 hour for the state
To align theincluding,
application
1915(c) HCBS regulation
to add the training
requirements.
requirements to the waiver
application.

Added new C-1-d: Remote/Telehealth
Delivery of Waiver Services
Remote delivery of services option

C-2-b: Abuse Registry Screening

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

C-2-d: Provision of Personal Care or Similar Services by
Legally Responsible Individuals.

Added language to define extraordinary Rev
care as "exceeding the ordinary care that
would be provided to a person without a
disability or chronic illness of the same
age." Also made some minor wording
changes such as the removal of the words
"and typically includes" and "spouse of a
waiver participant."

Appendix C-2-d & C-2-e

Added to the instructions: "When the
Add
relative/legal guardian has decisionmaking authority over the selection of
providers of waiver services, specify the
the state’s process for ensuring that the
legally responsible individual uses
substituted judgement on behalf of the
individual..." Also made other additions
to align with the current CMS review
criteria.
Removed independence plus designation. Del

Appendix E: Participant Direction of Services

Add

Burden
Change

Reason
for
Change

Type of
Change

2023
(new
version)

2020
(old
version)

Appendix C-1

States have the option to add the Yes. Add 2 hours
option for a waiver service to be
delivered via telehealth. If a state
chooses this option, the waiver
application will reflect that this is
an option to be transparent to the
public, and include safeguards to
ensure individual safety, privacy,
and community integration.

If the state maintains abuse
registries, this addition is to
ensure that states include in the
waiver application their process
for ensuring waiver participant
continuity of care if their waiver
service provider is added to a
state registry.
Clarifies language to specify
existing policy regarding legally
responsible individuals providing
waiver services and the definition
of extraordinary care.

Yes. Add 1 hour for states to
describe the process in the
waiver application.

To align with current exisiting
policy.

Yes. Add 1 hour.

No

Technical Correction. This
No
designation is not applicable and
was removed in previous updates
but missed in this section of the
waiver application.

Appendix C-2 (new section)

Appendix C-5: Settings

Added another item to list of items,
Rev
health homes including a check-off box
and instruction for state to complete item
C-1-c.

Add
Added a new section C-2-g, State Option
to Provide HCBS in Acute Care Hospitals
in accordance with Section 1902(h)(1) of
the Act. If the state chooses this option
the state can do so under the conditions
required by regulation and specified
under this item. By checking the boxes,
the state assures that it will meet these
conditions. A text box was also added to
for states to specify the waiver HCBS that
can be provided that are not duplicative
of services available in the acute care
hospital setting, how the HCBS will assist
the individual in returning to the
community. If there is any difference
from the typically billed rate for these
HCBS provided during a hospitalization,
the state is reminded to include this
information in Appendix I-2-a.
Removed statewide transition plan (STP) Rev.
language. Split existing text box into two.
Added new check boxes for states to
check to assure that they will meet/are
meeting regulation requirements. and,
when applicable, radio buttons (i.e.,
when a waiver includes provider-owned
or controlled settings).

Burden
Change

Reason
for
Change

Type of
Change

2023
(new
version)

2020
(old
version)

Appendix C-1-b: provision of case management to waiver
participants

This change was added to reflect No.
when waiver case management is
funded under a Medicaid health
home authority. This was
previously missing from the list of
options.
Under section 3715 of the
Yes. Add 3 hours.
Coronavirus Aid, Relief, and
Economic Security (CARES) Act,
Congress added to the Social
Security Act under section
1902(h)(1) a new provision that
allows states the option to
provide HCBS in acute care
hospitals under certain
conditions.

Separated out the one large text
box into two text boxes to ease
the burden in reviewing and
updating the information that
states are required to submit.
Added checkboxes to take the
place of some of the information
that states are currently required
via text box, to reduce state
burden in completing this
information.

No additional
burden/reduces burden.
Estimate of reduced burden
is 5 hours.

Added language to the instruction, for
Add
states to include in the qualifications
training or competency requirements for
the HCBS settings criteria and personcentered plan development.

Appendix D-1-b: Service Plan Development Safeguards

Added the following regulation language: Rev
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.
Added the following language to the
second radio button:"Explain how the
HCBS waiver service provider is the only
willing and qualified entity in a
geographic area who can develop the
service plan" with a text box for the state
to fill out if this is applicable. In addition,
added the following which will include
check off boxes. Also removed "is
conducted in the best interest of the
participant" and replaced this with the
safeguards states are required to
implement in order to mitigate the
potential for conflict of interest in service
plan development.
Specified the previous language as sub- Rev
section "i" in order to add a new
subsection "ii" below this. Within subsection "i", added "(h) how the
participant engages in and/or directs the
planning process."

Appendix D-1-d

Burden
Change

Reason
for
Change

Type of
Change

2023
(new
version)

2020
(old
version)

Appendix D-1-a: Responsibility for Service Plan
Development

Given the importance of the role Yes. Add 1 hour.
of the person-centered service
plan in HCBS provision, the
qualifications for individuals
responsible for service plan
development should include the
training or competency
requirements for the HCBS
settings criteria and personcentered plan development.
Clarifies the information that
No. It reduces state burden
states were previously required to by an estimated 2 hours.
provide in one large text box into
one smaller text box for one
portion of the requirement and
check boxes (statements of
assurances) for the rest. Reduces
state and federal burden.

This is a technical clarification and No.
does not impose a new state
requirement.

Appendix D-1-h: The service plan is subject to at least
annual periodic review and update.

Added new subsection "ii" with check
boxes for states to select to assure they
will meet the HCBS Settings
Requirements for the Service Plan.
After "update" added "when the
individual’s circumstances or needs
change significantly, or at the request of
the individual"

add

rev

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

rev
Added the following language: 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 of
implementation of the service plan
except, at the option of the state, when
providers are given responsibility to
perform this function because such
individuals are the only willing and
qualified entity in a geographic area, and
the state devises conflict of interest
protections.
Added the following language to the
second radio button:"Explain how the
HCBS waiver service provider is the only
willing and qualified entity in a
geographic area who can monitor service
plan implementation" with a text box for
the state to fill out if this is applicable.
Also removed "is conducted in the best
interest of the participant" and replaced
this with the safeguards to mitigate the
potential for conflict of interest that
states are required to check off to attest
to their implementation.

Burden
Change

Reason
for
Change

Type of
Change

2023
(new
version)

2020
(old
version)

Appendix D-1-d (new subsection added)

Adds a set of statements for
Yes. Add 1 hour.
which states are to check off
boxes to assure compliance with
HCBS waiver regulations.
Additional language to specify
No.
more detail regarding when
updates are required. Language
aligns with current practice and
2014 final rule.
Technical clarification to language No.
to align with current practice and
2014 final rule.

Clarifies the information that
No. Reduces burden by 2
states were previously required to hours.
provide in one large text box into
one smaller text box for one
portion of the requirement and
check boxes (statements of
assurances) for the rest. Reduces
state and federal burden.

Appendix D QIS sub assurance: "Service plans address all
participants’ assessed needs (including health and safety
risk factors) and personal goals, either by waiver services or
through other means."

Changed to "Service plans are
Rev
updated/revised at least annually, when
the individual’s circumstances or needs
change significantly, or at the request of
the individual."
Added "and community integration" to Rev
this sub assurance.

Appendix G QIS sub assurance: "Performance measures in This lanaguage was deleted.
Del
this sub-assurance include all Appendix G performance
measures for waiver actions submitted before June 1,
2014."
Appendix I QIS: "(For waiver actions submitted before June This language was deleted.
Del
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.") and
"(Performance measures in
this sub-assurance include all Appendix I performance
measures for waiver actions submitted before June 1,
2014.)"
Quality and QIS (throughout the waiver application)
Added the following under Methods for Add
Remediation/Fixing Individual Problems:
"and the state’s method for analyzing
information from individual problems,
identifying systemic deficiencies, and
implementing remediation actions."

Burden
Change

Reason
for
Change

Type of
Change

2023
(new
version)

2020
(old
version)

Appendix D QIS sub assurance: "Service plans are
updated/revised at least annually or when warranted by
changes in waiver participant's needs."

Revised to align the subassurance No.
with current practice which
follows 2014 quality SMDL and
final regulations published in
2014.
No.
CMS agreed with this edit
suggested by a commenter to add
the words “and communityintegration” to this subassurance.
No.
This language was deleted
because it was out-of-date.

This language was deleted
because it was out-of-date.

No.

This is a technical clarification and No.
does not impose a new state
requirement.