Crosswalk: Technical Guide

References to provision of one
meal each day in some sections of
the document

Principal Features of the HCBS
Waiver Authority, Service Plan

Strengthening Waiver Quality
Assurance/Quality Improvement
section

Throughout the document, removed
references to January 2019 and Version 3.6.
Revised to Version 3.7. Changed "S" to "s"
for "state", where appropriate. Also spelled
out "section" where appropriate and used
the symbol where appropriate. In addition,
throughout the document, statutory and
Throughout the document, corrected
outdated language regarding meals to
waiver participants which may include up to
two meals each day and which do not
constitute a full nutritional regimen to
waiver participants who live in their own
private residence.
First sentence revised to add other titles for
the service plan and the regulation citation.
It now reads as follows: "The waiver
services that an individual will receive must
be incorporated into a written personcentered service plan (all references
throughout this document to “plan of care”
or “service plan” refer to the personcentered service plan described under 42
CFR § 441.301(c)(2))."
Removed title and paragraph below it.

Burden Change

Reason for Change

Type of Change

2022 (new version)

2020 (old version)

References to January 2019 as the
release date, Version 3.6, and
"State", references to "section",
statutory and regulatory citations

To update outdated language and make
corrections.
Rev

No.

Rev

To correct outdated language.

No.

Add

To add clarifying language.

No.

Del

To remove outdated language.

No.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesgnation.

Removed references to DEHPG and
replaced with MBHPG, removed references
to Regional Office (RO) and Central Office
(CO) and added Division of Long Term
Services and Supports (DLTSS), MCOG and
Division of Home and Community Based
Services Operations (DHCBSO)where
appropriate. Also made revisions
throughout based on changes in operations.
And updated the language regarding CMS
oversight of state waiver operations.
New Item added: Appendix K (not in the
Version 3.7 HCBS Waiver
waiver management system ): Emergency
Application Organization
Preparedness and Response. Separate
from the waiver management system
(WMS), states can request to add an
Waiver Application Submission
Added: Please note that in general, a state
Requirements, Processes, and
may not amend a waiver that is on a
Procedures, Temporary Extensions temporary extension. Instead, the state is
required to operate the waiver consistent
with
the most
current
CMS-approved
Waiver Application Submission
Removed
language
pertaining
to the HCB
Requirements, Processes, and
settings transition plans.
Procedures, Waiver Termination

Burden Change

Reason for Change

Type of Change

2022 (new version)

2020 (old version)

Federal Administration of HCBS
Waiver Authority, and throughout
the document: References to
Disabled and Elderly Health
Program Group (DEHPG), Regional
Office (RO), Division of Long Term
Services and Supports (DLTSS)

Rev

To update outdated language due to
organizational changes.

Add

To provide information regarding the option No.
for states to submit an Appendix K 1915(c)
waiver amendment in response to an
emergency.
To clarify in alignment with current existing No.
policy.

Rev

Del

To remove outdated language

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesgnation.

No.

No.

Detailed Instructions, Application
Format

Quality Improvement Strategy
sections

Add
Revised this section to remove outdated
language and add guidance and instructions
for state preparation and submission of the
form CMS-372(S) report.
Responsibility for Service Plan
Add
Development, added:"Given the
importance of the role of the personcentered service plan in HCBS provision, the
qualifications should include the training or
competency requirements for the HCBS
settings criteria and person-centered plan
development."
Throughout document, the following has
Add
been added: "along with the state’s method
for analyzing information from individual
problems, identifying systemic deficiencies,
and implementing remediation actions."

Item 1-F Level of Care: "The Deficit Removed statement.
Reduction Act provides for the
provision of home and communitybased alternatives to PRTFs on a
demonstration basis in ten states."

Del

Burden Change

Reason for Change

Type of Change

2022 (new version)

2020 (old version)

Post Approval Activities, Annual
Report Form 372(S)

To add guidance and instructions for state
No.
preparation and submission of the form CMS372(S) Report. Clarifies existing current
practice (not new).
Given the importance of the role of the
N/A (burden already
person-centered service plan in HCBS
added in Application
provision, the qualifications for individuals
crosswalk)
responsible for service plan development
should include the training or competency
requirements for the HCBS settings criteria
and person-centered plan development.
To add missing langauge. Does not impose
new requirements.

No.

To remove outdated language.

No.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesgnation.

Del

To remove outdated language.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesgnation.

Burden Change

Reason for Change

Type of Change

2022 (new version)

2020 (old version)

Item 6-f- FFP Limitation: "§1903(c) Removed paragraph.
of the Act provides an exception to
the principle that Medicaid is the
payor of last resort in the case of
Medicaid-reimbursable services
that are included in a child’s
Individual Education Plan (IEP)
under the provisions of the
Individuals with Disabilities
Education Improvement Act of
2004 (IDEA). However, this
exception only applies to those
services that also are reimbursable
under the Medicaid state plan
(including services required under
EPSDT). This exception does not
apply to waiver services."

No.

Added the following note in several
Rev
To clarify that in 1915(c) waivers that include No.
sections in Appendix A, and in Appendix B-6the 42 CFR § 435.217 special home and
b: "In 1915(c) waivers that include the 42
community-based services waiver eligibility
CFR § 435.217 special home and
group, Medicaid eligibility determinations
community-based services waiver eligibility
can only be performed by the SMA or a
group, Medicaid eligibility determinations
government agency delegated by the SMA in
can only be performed by the State
accordance with 42 CFR § 431.10.
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-ofcare 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-ofcare assessment tool. States should ensure
that any use of an assessment tool by a nongovernmental entity to evaluate/determine
an individual’s required level-of-care
involves no discretion by the nongovernmental entity and that the
Type of Change:
= Revision, Del
= Deletion, Add = Addition, and Red = Redesgnation.
development
of theRev
requirements,
rules,

Burden Change

Reason for Change

Type of Change

2022 (new version)

2020 (old version)

Appendix A, and Appendix B-6-b

Burden Change

Reason for Change

Type of Change

2022 (new version)

2020 (old version)

Appendix A, Quality Improvement: Removed this outdated language.
"…for waiver actions submitted on
or after March 17, 2014"

Del

To remove outdated langauge.

Appendix B-4-b, technical guidance Added the following note: "Note: While not
affecting any of a state’s choices or
elections in Appendix B-4, states should be
aware, for eligibility-related purposes, that
they
may target
restrictive
financial
Appendix B-5-Post-Eligibility
Throughout
this less
section,
amended
the
Treatment of Income, Overview
extension date that states must use spousal
section
impoverishment rules from September 30,
2019 to September 30, 2027 (or other date
as
required
Appendix B-5: Post-Eligibility
Revisions
toby
thelaw).
instructions to include
Treatment of Income
information about authority enacted in
2019 that permits states the option to
disregard spousal income and resources
when
determining
Medicaid
eligibility for
Appendix B-5-b-1, B-5-b-2, B-5-c,
B-5 General
Guidance
Regarding
and B-5-d
Completing B-5; Language has been revised
to read: Items B-5-b, B-5-c, and B-5-d apply
for time periods after September 30, 2027
other
date as required
law).Item
It B-5Appendix B-5-b-1/Item B-5-b-2 and (or
Item
B-5-b-1/Item
B-5-b-2by
is now
B-5-c-1/Item B-5-c-2 i
b. In addition, Item B-5-c-1/Item B-5-c-2 is
now Item B-5-c. These changes are made
throughout the document.

Add

To add a note for state awareness that states No.
are permitted, for eligibility-related
purposes, to target less restrictive financial
methodologies at individuals in need of HCBS
authorized
under
sectiondate.
1915(c) of the Act No.
To update the
extension

Rev

No.

Rev

To add guidance to states about this state
option per State Medicaid Director (SMD)
letter #21-004 (December 7, 2021).

Rev

To update subsections of Appendix B-5 that No.
currently reference the period prior to
January 1, 2014 to instead refer only to
periods during the mandatory application of
the
spousalsections
impoverishment
provisions for No.
To update
referenced.

Rev

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesgnation.

No.

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

This previously included the 2014-2019
Rev
dates which are outdated and were
removed. Section 1634 was added. Similar
changes have been made throughout the
document.reference to B-6-h and replaced Rev
Removed
with B-6-f.

Revised to clarify that waiver level of care
determinations may be made directly by
the SMA or another entity under contract
with the SMA, and removed references to
42 CFRC-1-b,
§ 431.10.
Appendix C-1-b, Alternate Provision Under
added the following
of Case Management Services to
language:"Given that case managers are
Waiver Participants- N/A (new
critical for ensuring that regulatory
language added), Appendix C-1-c, requirements for both person-centered
Delivery ofC-1
Case Management
planning
and HCBS
settings
met, states
Appendix
A
new section,
C-1-d
is beingare
added:Item
C1-d: Remote/Telehealth Delivery of Waiver
Services
Instructions
Specify in this
the chart
whether each waiver
Appendix C-2-a, Criminal
Removed
language.
History/Background Investigations:
"The state must also list the crimes
that bar individuals/entities from
working in Medicaid."

Rev

Add

Add

Del

Burden Change

Reason for Change

Type of Change

2022 (new version)

2020 (old version)

Appendix B-5-e, f, and g

To remove outdated dates.

No.

To correct this reference.

No.

To clarify that 42 CFR § 431.10 applies to
No.
Medicaid eligibility determinations overall,
and that Appendix B-6-b is specific to waiver
level of care determinations.
To align the application with 1915(c) HCBS
N/A This is already
regulation requirements.
accounted for in the
waiver application.
States have the option to add the option for
a waiver service to be delivered via
telehealth. If a state chooses this option, the
waiver will reflect that this is an option and
include
state safeguards
to ensure
individual
This
information
is state specific
and
not
needed for purposes of the waiver
application.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesgnation.

N/A This is already
accounted for in the
waiver
application.(Add 4
hours if the state
No.

Burden Change

Reason for Change

Type of Change

2022 (new version)

2020 (old version)

Appendix C-2-b Abuse Registry
Screening: N/A (new language)

Added a new item "(d)" to the instructions Add
and review criteria: "the process for
ensuring continuity of care for a waiver
participant whose service provider was
added updates
to the abuse
registry."
Appendix C-2-c, Facilities Subject to Minor
to language.
Rev
Section 1616(e) of the Social
Security Act

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
add
minor
updates
and language
improvements.

N/A This is already
accounted for in the
waiver application.

Appendix C-2-d: provision of
Under technical guidance, spouse was
personal care or similar services by removed as an example when discussing
legally responsible individuals
legally responsible individuals

Del

No.

Item C-2-d: provision of personal
care or similar services by legally
responsible individuals

Rev &
Add

To remove spouse as an example since
spouses may not always be legally
responsible individuals, depending on state
law.
To provide additional guidance for states
about current exisiting policy.

Added language to define extraordinary
care as "exceeding the ordinary care that
would be provided to a person without a
disability or chronic illness of the same
age."following
Added alanguage
requirement
that state
Item C-2-e- state policies
The
was deleted:
concerning payment for waiver
"...especially when the legal guardian
services furnished by relatives/legal exercises decision making authority on
guardians
behalf of the participant in the selection of
waiver aproviders"
added
"When
theto
Appendix C-2
Added
new item:and
C-2-g:
State
Option
Provide HCBS in Acute Care Hospitals instructions, technical guidance, and review
criteria

Add,De To clarify and align with current exisiting
l
policy.

Add

No.

No.

No.

To align with section 3715 of the Coronavirus N/A This is already
Aid, Relief, and Economic Security (CARES)
accounted for in the
Act, which Congress added to the Social
waiver application.
Security Act under section 1902(h)(1), to add
allow states the option to provide HCBS in

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesgnation.

Appendix C-3, Requirements
Concerning the Specification of the
Scope of Services: "When
specifying the scope of a service do
not use terms such as "including
but not limited to . . .," "for
example . . .," “including . . .,"
“etc.”
Appendix C-3-d (under "Additional
Considerations Concerning Service
Coverage"), Children's Education
Services and C-3 Education Services
core service
definition
C-3-j
Provision
of Waiver Services
Out of State-

Appendix C-3

Burden Change

Reason for Change

Type of Change

2022 (new version)

2020 (old version)

Appendix C-3, Relationship to
EPSDT Services

Updated language to remove "(Please note Rev
that any encounter with a health care
professional practicing within the scope of
his/her practice is considered an interperiodic“e.g”
screening.). That is, under EPSDT Rev
Added

To clarify existing policy.

No.

To add another example of an open-ended
response, which is not permitted.

No.

Updated language and regulatory citations. Rev
Also added new language to C-3-d (some of
which is the same as language under C-3
education services) so that it now reads:
Add
"Section
1915(c)(5)(C)
The
following
sentenceindicates
has beenthat
added
"This includes assuring the health and
welfare of the waiver participant and
monitoring compliance with HCBS settings
criteria."
Added
new item "L. Electronic/Remote
New
Monitoring HCBS" with guidance and
instructions

To update language, align language in these No.
two sections, and update regulatory
citations.
To add clarification to existing language.

No.

If states choose to add remote monitoring
For states that choose
and remote monitoring equipment inside of this option, yes, add 2
a waiver service the waiver application, the hours.
waiver will reflect this and include state
safeguards to ensure individual safety,

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesgnation.

Burden Change

Reason for Change

Type of Change

2022 (new version)

2020 (old version)

Appendix C-5 Home and
Community-Based Settings
Requirements-

In the instructions, revised the instructions, Rev
technical guidance, and review criteria.

Appendix C-3- Core Service
Definitions-

Revisions to core service definitions to add Add/Rev To make technical edits.
statuatory/regulatory citations, and other
minor changes

Community Transition Services core
service definition and
guidance,"provider-operated living
arrangement", and ""institution"
Throughout document, references
to Medicaid being claimed by the
state as a Medicaid administrative
activity or cost.
Appendix C-3, N/A (new)

Added "controlled." Added "Medicaidfunded" in front of "institution."

Add

To make technical edits to align with
requirements.

Added "in accordance with CMS-approved
cost allocation plan"

Add

Technical edits (already in current version in No.
some places but was missing in others)

Added a new core service definition and
instructions for "Assistance in Community
Integration – Housing Supports."

Add

Appendix C-3, N/A (new)

Under Extended State Plan Services, in the Add
discussion paragraph, added the following
sentence at the end of the paragraph:
"Extended state plan services may not
supplant medically necessary Section

To add a suggested core service definition
No.
and instructions for a service that states
have the option to add currently. This is not
new as states have the option to include this
No.
service
now.
To
clarify
existing current policy.

To specify current existing policy and clarify
guidance regarding the information states
are to include in the waiver application.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesgnation.

N/A This is already
accounted for in the
waiver application.
No.

No.

Appendix D-1-b, Service Plan Development
Safeguards- Added the following
language:"to mitigate the potential for
conflict of interest", and removed the
following langauge
from thisthe
section
and
Previous version was missing the
Appendix
D-1-c, Supporting
Participant
words "person-centered"
in Service Plan Development, in this section
and throughout the document, the words
"person-centered" have been added when
referencing
the service
plan so Service
that it reads
Appendix D-1-d (added new
Appendix
D-1-d
is now D-1-d-i,
Plan
subsection title "i" and missing
Development Process. In this section,
language)
interim service plan is also now a
provisional service plan. In addition
langauge
has been
added
that D-1-d-ii.
the duration
Appendix D-1-d-ii (new subsection The
following
is newly
added:
HCB
added)
Settings Requirements for the Service Plan:
Instructions, By checking the boxes below
in the waiver application, the state is
assuringa statement
that the following
willthat
be included
Appendix D-1-g: : Process for
Added
to convey
the state
Making Service Plan Subject to the sample of service plans must be
Approval of the Medicaid Agency representative of the demographic makeup
of the waiver population. Also added the
underlined
new
language
tobeen
the CMS
Appnedix D-1-h, Service Plan
The
following
language
has
added
Review and Update
"...when the individual’s circumstances or
needs change significantly, or at the
request of the individual."
Appendix D-2-a, Service Plan
the following language has been added:
Implementation and Monitoring
"...and adherence to the HCB settings
criteria"

Rev

Burden Change

Reason for Change

Type of Change

2022 (new version)

2020 (old version)

Appendix D-1-b (Service Plan
Development Safeguards)

To clarify the information that states were
previously required to provide in the waiver
application (from one large text box into one
smaller text box for one portion of the
requirement
andconsistent
check boxes
of
To
align and be
with(statements
current
terminology.

N/A. This is already
accounted for in the
waiver application.

Rev

To make a technical clarification. This does
not impose a new state requirement.

No.

Add

Adds a set of statements for which states are N/A This is already
to check off boxes to assure compliance with accounted for in the
HCBS waiver regulations.
waiver application.

Add

To add clarity to existing current
requirements.

No.

Add

To align with regulation language and
current practice.

No.

Add

To align language with current practice and
2014 final rule.

No.

Add

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesgnation.

No.

Rev.
Outdated langauge was removed and
To clarify the information that states were
additional language was added. This
previously required to provide in the waiver
section now reads as follows: Indicate
application (previously one large text box
whether entities and/or individuals that are
and changed to one smaller text box for one
responsible for monitoring service plan
portion of the requirement and check boxes
implementation and participant health and
(statements of assurances) for the rest).
welfare are permitted to provide other
direct (non-case management) services to
the same waiver participant because they
only willing and qualified entity in a
geographic area who can monitor service
plan implementation. If such entities
and/or individuals are permitted to furnish
other direct waiver services to the same
waiver participant, explain that the HCBS
waiver service provider is the only willing
and qualified entity in a geographic area
who can monitor service plan
implementation for the same waiver
participant and specify the safeguards to
mitigate potential conflict of interest in
monitoring of service plan implementation,
participant health and welfare, and
adherence to the HCB settings
requirements. Technical Guidance. As
described in 42 CFR § 441.301(c)(1)(vi),
providers of HCBS for the individual, or
those who have interest in or are employed
of Change:
Revare
= Revision,
Del = Deletion,
Add = Addition, and Red = Redesgnation.
by Type
a provider
of HCBS,
not permitted
to

Burden Change

Reason for Change

Type of Change

2022 (new version)

2020 (old version)

Appendix D-2-b, Monitoring
Safeguards

N/A (burden
reduction already
added in Application
crosswalk)

Rev
Revised "when warranted by changes in
the waiver participant's needs " to "when
the individual’s circumstances or needs
change significantly, or at the request of the
individual." Added a missing subassurance:
"The state monitors service plan
development in accordance with its policies
and procedures." Similar changes were
made to the CMS Review Criteria for this
section. Also added an edit for one of the
service plan sub assurances in Appendix D
to specify: "Service plans address all
participants’ assessed needs (including
health and safety risk factors) and personal
and community integration goals, either by
waiver services or through other means."

To add technical edits.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesgnation.

Burden Change

Reason for Change

Type of Change

2022 (new version)

2020 (old version)

Appendix D Quality Improvement,
Service Plan

No.