Application for 1915(c) HCBS Waiver: Draft = GU.11.00.00

From: Subject: Application for 1915(c) HCBS Waiver: Draft GU.11.00.00 Date: Wed, 22 Apr 2009 16:25:04 -0400 MIME-Version: 1.0 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: file://C:\Documents and Settings\ht80\Local Settings\Temporary Internet Files\Content.Outlook\5IG7V5O5\Application for 1915(c) HCBS Waiver.htm X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 Application for 1915(c) HCBS Waiver: Draft = GU.11.00.00

Application for=20 a =A71915(c) Home and Community-Based Services Waiver

PURPOSE OF THE HCBS WAIVER PROGRAM

The Medicaid Home and Community-Based Services (HCBS) = waiver=20 program is authorized in =A71915(c) of the Social Security Act. The = program=20 permits a State to furnish an array of home and community-based services = that=20 assist Medicaid beneficiaries to live in the community and avoid=20 institutionalization. The State has broad discretion to design its = waiver=20 program to address the needs of the waiver=92s target population. Waiver = services=20 complement and/or supplement the services that are available to = participants=20 through the Medicaid State plan and other federal, state and local = public=20 programs as well as the supports that families and communities provide. =

The Centers for Medicare & Medicaid Services (CMS) = recognizes=20 that the design and operational features of a waiver program will vary = depending=20 on the specific needs of the target population, the resources available = to the=20 State, service delivery system structure, State goals and objectives, = and other=20 factors. A State has the latitude to design a waiver program that is=20 cost-effective and employs a variety of service delivery approaches, = including=20 participant direction of services.

Application for a = =A71915(c) Home=20 and Community-Based Services Waiver

1. Request Information (1 of = 3)

The State of = Guam requests approval = for a=20 Medicaid home and community-based services (HCBS) waiver under the = authority=20 of =A71915(c) of the Social Security Act (the Act).
Program=20 Title (optional - this=20 title will be used to locate this waiver in the finder): =

=20
Type of=20 Request: new

New to replace waiver =

Replacing = Waiver=20 Number:=20

Migration Waiver - this is an existing approved=20 waiver

Provide the information about the original=20 waiver being=20 migrated

Base Waiver = Number: =

Amendment Number =

(if=20 applicable): =20

Effective Date: (mm/dd/yy)

Draft=20 ID: GU.11.00.00
Type of Waiver (select = only=20 one):
=20
Proposed=20 Effective Date:=20 (mm/dd/yy)

1. Request Information (2 of = 3)

Level(s) of Care. This = waiver is=20 requested in order to provide home and community-based waiver services = to=20 individuals who, but for the provision of such services, would require = the=20 following level(s) of care, the costs of which would be reimbursed = under the=20 approved Medicaid State plan (check each that applies): =

Hospital

Select applicable level of care=20
Hospital as defined in 42 CFR = =A7440.10=20

If=20 applicable, specify whether the State additionally limits the waiver = to=20 subcategories of the hospital level of care:

Character Count: = =20 out of = 6000=20

=20

Inpatient psychiatric facility for = individuals=20 age 21 and under as provided in42 CFR =A7440.160

not selected

Nursing=20 Facility

Select applicable level of care=20
Nursing Facility As defined in 42 CFR = =A7440.40=20 and 42 CFR =A7440.155

If=20 applicable, specify whether the State additionally limits the waiver = to=20 subcategories of the nursing facility level of care: =

Character Count: = =20 out of = 6000=20

=20

Institution for Mental Disease for = persons with=20 mental illnesses aged 65 and older as provided in 42 CFR = =A7440.140=20

not selected

Intermediate Care Facility for the Mentally = Retarded=20 (ICF/MR) (as defined in 42 CFR =A7440.150)

If=20 applicable, specify whether the State additionally limits the waiver = to=20 subcategories of the ICF/MR level of care:

Character Count: = =20 out of = 6000

=20

1. Request Information (3 of = 3)

Concurrent Operation with Other = Programs.=20 This waiver operates concurrently with = another=20 program (or programs) approved under the following authorities =

Select one:

Not applicable

Applicable

Check the applicable authority or = authorities:

Services = furnished under=20 the provisions of =A71915(a)(1)(a) of the Act and described in = Appendix=20 I

Waiver(s) = authorized under=20 =A71915(b) of the Act.

Specify = the=20 =A71915(b) waiver program and indicate whether a =A71915(b) waiver = application has=20 been submitted or previously approved:

Character = Count:=20 out of 6000 =

=20

Specify the=20 =A71915(b) authorities under which this program operates (check = each that=20 applies):

=A71915(b)(1) = (mandated=20 enrollment to managed care)

=A71915(b)(2) = (central=20 broker)

=A71915(b)(3) = (employ cost=20 savings to furnish additional services)

=A71915(b)(4) = (selective=20 contracting/limit number of providers) =

A program = operated under=20 =A71932(a) of the Act.

Specify = the nature=20 of the State Plan benefit and indicate whether the State Plan = Amendment has=20 been submitted or previously approved:

Character = Count:=20 out of 6000 =

=20

A program = authorized under=20 =A71915(i) of the Act.

A program = authorized under=20 =A71915(j) of the Act.

A program = authorized under=20 =A71115 of the Act.

Specify = the=20 program:

Character = Count:=20 out of 6000 =

=20

=20 Not applicable =

not = selected

2. Brief Waiver Description

Brief Waiver Description. In one page or = less, = briefly describe=20 the purpose of the waiver, including its goals, objectives, = organizational=20 structure (e.g., the roles of state, local and other entities), and = service=20 delivery methods.

Character = Count:=20 out of 6000

=20

3. Components of the Waiver Request

The waiver application consists of the = following=20 components. Note: Item 3-E must be completed. =

Waiver Administration and = Operation.=20 Appendix A specifies the administrative and = operational=20 structure of this waiver.
Participant Access and = Eligibility.=20 Appendix B specifies the target group(s) of = individuals who=20 are served in this waiver, the number of participants that the State = expects=20 to serve during each year that the waiver is in effect, applicable = Medicaid=20 eligibility and post-eligibility (if applicable) requirements, and = procedures=20 for the evaluation and reevaluation of level of care.
Participant Services. = Appendix=20 C specifies the home and community-based waiver services that = are=20 furnished through the waiver, including applicable limitations on such = services.
Participant-Centered Service Planning = and=20 Delivery. Appendix D specifies the = procedures and=20 methods that the State uses to develop, implement and monitor the=20 participant-centered service plan (of care).
Participant-Direction of Services. = When the State provides for participant direction = of=20 services, Appendix E specifies the participant = direction=20 opportunities that are offered in the waiver and the supports that are = available to participants who direct their services. (Select = one):=20

Yes. This waiver provides = participant=20 direction opportunities. Appendix E is=20 required.

No. This waiver does = not provide=20 participant direction opportunities. Appendix E is not required.

not = selected
Participant Rights. = Appendix=20 F specifies how the State informs participants of their = Medicaid Fair=20 Hearing rights and other procedures to address participant grievances = and=20 complaints.
Participant Safeguards.=20 Appendix G describes the safeguards that the State = has=20 established to assure the health and welfare of waiver participants in = specified areas.
Quality Improvement Strategy. = Appendix H contains the Quality Improvement Strategy = for this=20 waiver.
Financial Accountability.=20 Appendix I describes the methods by which the State = makes=20 payments for waiver services, ensures the integrity of these payments, = and=20 complies with applicable federal requirements concerning payments and = federal=20 financial participation.
Cost-Neutrality = Demonstration.=20 Appendix J contains the State's demonstration that = the waiver=20 is cost-neutral.

4. Waiver(s) Requested

Comparability. The State = requests a=20 waiver of the requirements contained in =A71902(a)(10)(B) of the Act = in order to=20 provide the services specified in Appendix C that are = not=20 otherwise available under the approved Medicaid State plan to = individuals who:=20 (a) require the level(s) of care specified in Item 1.F and (b) meet = the target=20 group criteria specified in Appendix B.
Income and Resources for the = Medically=20 Needy. Indicate whether the State requests a waiver of=20 =A71902(a)(10)(C)(i)(III) of the Act in order to use institutional = income and=20 resource rules for the medically needy (select one):

Not Applicable

No

Yes

not selected
Statewideness. Indicate = whether the=20 State requests a waiver of the statewideness requirements in = =A71902(a)(1) of=20 the Act (select one):

No

Yes

If yes, specify the waiver of statewideness = that is=20 requested (check each that applies):

Geographic = Limitation.=20 A waiver=20 of statewideness is requested in order to furnish services under this = waiver=20 only to individuals who reside in the following geographic areas or = political=20 subdivisions of the State.

Specify the areas to which = this waiver=20 applies and, as applicable, the phase-in schedule of the waiver by = geographic=20 area:

Character = Count:=20 out of 6000 =

=20

Limited = Implementation of=20 Participant-Direction. A waiver of statewideness is = requested in=20 order to make participant-direction of services = as=20 specified in Appendix E available only to individuals who = reside in=20 the following geographic areas or political subdivisions of the State. = Participants who reside in these areas may elect to direct their = services as=20 provided by the State or receive comparable services through the = service=20 delivery methods that are in effect elsewhere in the = State.=20

Specify the areas of the State = affected=20 by this waiver and, as applicable, the phase-in schedule of the waiver = by=20 geographic area:

Character = Count:=20 out of 6000 =

=20

5. Assurances

In accordance with 42 CFR =A7441.302, the State = provides the=20 following assurances to CMS:

Health & Welfare: The = State assures=20 that necessary safeguards have been taken to protect the health and = welfare of=20 persons receiving services under this waiver. These safeguards = include:
1. As specified in Appendix C, = adequate=20 standards for all types of providers that provide services under = this=20 waiver;
2. Assurance that the standards of any State = licensure or=20 certification requirements specified in Appendix C = are met=20 for services or for individuals furnishing services that are = provided under=20 the waiver. The State assures that these requirements are met on the = date=20 that the services are furnished; and,
3. Assurance that all facilities subject to = =A71616(e) of=20 the Act where home and community-based waiver services are provided = comply=20 with the applicable State standards for board and care facilities as = specified in Appendix C.
Financial Accountability. The = State=20 assures financial accountability for funds expended for home and=20 community-based services and maintains and makes available to the = Department=20 of Health and Human Services (including the Office of the Inspector = General),=20 the Comptroller General, or other designees, appropriate financial = records=20 documenting the cost of services provided under the waiver. Methods of = financial accountability are specified in Appendix = I.
Evaluation of Need: The State = assures=20 that it provides for an initial evaluation (and periodic = reevaluations, at=20 least annually) of the need for a level of care specified for this = waiver,=20 when there is a reasonable indication that an individual might need = such=20 services in the near future (one month or less) but for the receipt of = home=20 and community based services under this waiver. The procedures for = evaluation=20 and reevaluation of level of care are specified in Appendix=20 B.
Choice of Alternatives: The State assures that = when an=20 individual is determined to be likely to require the level of care = specified=20 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=20 waiver; and,
2. Given the choice of either institutional or = home and=20 community based waiver services. Appendix B = specifies the=20 procedures that the State employs to ensure that individuals are = informed of=20 feasible alternatives under the waiver and given the choice of = institutional=20 or home and community-based waiver services.
Average Per Capita = Expenditures: The=20 State assures that, for any year that the waiver is in effect, the = average per=20 capita expenditures under the waiver will not exceed 100 percent of = the=20 average per capita expenditures that would have been made under the = Medicaid=20 State plan for the level(s) of care specified for this waiver had the = waiver=20 not been granted. Cost-neutrality is demonstrated in Appendix=20 J.
Actual Total Expenditures: = The State=20 assures that the actual total expenditures for home and = community-based waiver=20 and other Medicaid services and its claim for FFP in expenditures for = the=20 services provided to individuals under the waiver will not, in any = year of the=20 waiver period, exceed 100 percent of the amount that would be incurred = in the=20 absence of the waiver by the State's Medicaid program for these = individuals in=20 the institutional setting(s) specified for this waiver.
Institutionalization Absent = Waiver: The=20 State assures that, absent the waiver, individuals served in the = waiver would=20 receive the appropriate type of Medicaid-funded institutional care for = the=20 level of care specified for this waiver.
Reporting: The State assures = that=20 annually it will provide CMS with information concerning the impact of = the=20 waiver on the type, amount and cost of services provided under the = Medicaid=20 State plan and on the health and welfare of waiver participants. This=20 information will be consistent with a data collection plan designed by = CMS.
Habilitation Services. The = State=20 assures that prevocational, educational, or supported employment = services, or=20 a combination of these services, if provided as habilitation services = under=20 the waiver are: (1) not otherwise available to the individual through = a local=20 educational agency under the Individuals with Disabilities Education = Act=20 (IDEA) or the Rehabilitation Act of 1973; and, (2) furnished as part = of=20 expanded habilitation services.
Services for Individuals with Chronic = Mental=20 Illness. The State assures that federal financial = participation (FFP)=20 will not be claimed in expenditures for waiver services including, but = not=20 limited to, day treatment or partial hospitalization, psychosocial=20 rehabilitation services, and clinic services provided as home and=20 community-based services to individuals with chronic mental illnesses = if these=20 individuals, in the absence of a waiver, would be placed in an IMD and = are:=20 (1) age 22 to 64; (2) age 65 and older and the State has not included = the=20 optional Medicaid benefit cited in 42 CFR =A7440.140; or (3) age 21 = and under=20 and the State has not included the optional Medicaid benefit cited in = 42 CFR =A7=20 440.160.

6. Additional Requirements

Note: Item 6-I must be completed.

Service Plan. In accordance = with 42 CFR=20 =A7441.301(b)(1)(i), a participant-centered service plan (of care) is = developed=20 for each participant employing the procedures specified in = Appendix=20 D. All waiver services are furnished pursuant to the service = plan.=20 The service plan describes: (a) the waiver services that are furnished = to the=20 participant, their projected frequency and the type of provider that = furnishes=20 each service and (b) the other services (regardless of funding source, = including State plan services) and informal supports that complement = waiver=20 services in meeting the needs of the participant. The service plan is = subject=20 to the approval of the Medicaid agency. Federal financial = participation (FFP)=20 is not claimed for waiver services furnished prior to the development = of the=20 service plan or for services that are not included in the service = plan.
Inpatients. In accordance = with 42 CFR=20 =A7441.301(b)(1) (ii), waiver services are not furnished to = individuals who are=20 in-patients of a hospital, nursing facility or ICF/MR.
Room and Board. In accordance = with 42=20 CFR =A7441.310(a)(2), FFP is not claimed for the cost of room and = board except=20 when: (a) provided as part of respite services in a facility approved = by the=20 State that is not a private residence or (b) claimed as a portion of = the rent=20 and food that may be reasonably attributed to an unrelated caregiver = who=20 resides in the same household as the participant, as provided in=20 Appendix I.
Access to Services. The State = does not=20 limit or restrict participant access to waiver services except as = provided in=20 Appendix C.
Free Choice of Provider. In = accordance=20 with 42 CFR =A7431.151, a participant may select any willing and = qualified=20 provider to furnish waiver services included in the service plan = unless the=20 State has received approval to limit the number of providers under the = provisions of =A71915(b) or another provision of the Act.
FFP Limitation. In accordance = with 42=20 CFR =A7433 Subpart D, FFP is not claimed for services when another = third-party=20 (e.g., another third party health insurer or other federal or state = program)=20 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=20 charge, or as free care to the community. Services will not be = considered to=20 be without charge, or free care, when (1) the provider establishes a = fee=20 schedule for each service available and (2) collects insurance = information=20 from all those served (Medicaid, and non-Medicaid), and bills other = legally=20 liable third party insurers. Alternatively, if a provider certifies = that a=20 particular legally liable third party insurer does not pay for the = service(s),=20 the provider may not generate further bills for that insurer for that = annual=20 period.
Fair Hearing: The State = provides the=20 opportunity to request a Fair Hearing under 42 CFR =A7431 Subpart E, = to=20 individuals: (a) who are not given the choice of home and community- = based=20 waiver services as an alternative to institutional level of care = specified for=20 this waiver; (b) who are denied the service(s) of their choice or the=20 provider(s) of their choice; or (c) whose services are denied, = suspended,=20 reduced or terminated. Appendix F specifies the = State's=20 procedures to provide individuals the opportunity to request a Fair = Hearing,=20 including providing notice of action as required in 42 CFR =A7431.210. =
Quality Improvement. The = State operates=20 a formal, comprehensive system to ensure that the waiver meets the = assurances=20 and other requirements contained in this application. Through an = ongoing=20 process of discovery, remediation and improvement, the State assures = the=20 health and welfare of participants by monitoring: (a) level of care=20 determinations; (b) individual plans and services delivery; (c) = provider=20 qualifications; (d) participant health and welfare; (e) financial = oversight=20 and (f) administrative oversight of the waiver. The State further = assures that=20 all problems identified through its discovery processes are addressed = in an=20 appropriate and timely manner, consistent with the severity and nature = of the=20 problem. During the period that the waiver is in effect, the State = will=20 implement the Quality Improvement Strategy specified in = Appendix=20 H.
Public Input. Describe how the State = secures public=20 input into the development of the waiver:

Character = Count:=20 out of 6000 =

=20
Notice to Tribal Governments. = The State=20 assures that it has notified in writing all federally-recognized = Tribal=20 Governments that maintain a primary office and/or majority population = within=20 the State of the State's intent to submit a Medicaid waiver request or = renewal=20 request to CMS at least 60 days before the anticipated submission date = is=20 provided by Presidential Executive Order 13175 of November 6, 2000. = Evidence=20 of the applicable notice is available through the Medicaid Agency. =
Limited English Proficient = Persons. The=20 State assures that it provides meaningful access to waiver services by = Limited=20 English Proficient persons in accordance with: (a) Presidential = Executive=20 Order 13166 of August 11, 2000 (65 FR 50121) and (b) Department of = Health and=20 Human Services "Guidance to Federal Financial Assistance Recipients = Regarding=20 Title VI Prohibition Against National Origin Discrimination Affecting = Limited=20 English Proficient Persons" (68 FR 47311 - August 8, 2003). = Appendix=20 B describes how the State assures meaningful access to waiver = services by Limited English Proficient persons.

7. Contact Person(s)

The Medicaid agency representative with whom = CMS=20 should communicate regarding the waiver is:

Last Name: =
First Name: =
Title:
Agency:
Address: =
Address 2: =
City:
State:	Guam
Zip:	=
Phone:	= Ext: TTY=20
Fax:	=
E-mail: =

If applicable, the State operating agency=20 representative with whom CMS should communicate regarding the waiver = is:

Last=20 Name:
First=20 Name:
Title: =
Agency:
Address: =
Address 2: =
City:
State: =	Guam=20
Zip:	=
Phone:	= Ext: TTY=20
Fax:	=
E-mail: =	=

8. Authorizing Signature

This document, together with = Appendices A=20 through J, constitutes the State's request for a waiver under =A71915(c) = of the=20 Social Security Act. The State assures that all materials referenced in = this=20 waiver application (including standards, licensure and certification=20 requirements) are readily available in print = or=20 electronic form upon request to CMS through the Medicaid agency or, if=20 applicable, from the operating agency specified in Appendix A. Any = proposed=20 changes to the waiver will be submitted by the Medicaid agency to CMS in = the=20 form of waiver amendments.

Upon approval by CMS, the waiver = application=20 serves as the State's authority to provide home and community-based = waiver=20 services to the specified target groups. The State attests that it will = abide by=20 all provisions of the approved waiver and will continuously operate the = waiver=20 in accordance with the assurances specified in Section 5 and the = additional=20 requirements specified in Section 6 of the request.

Signature: =
	State Medicaid Director or = Designee
Submission = Date:=20	=

Last = Name:
First = Name:
Title: =
Agency: =
Address: =
Address=20 2:
City: =
State: =	Guam
Zip:
Phone: =
Fax:
E-mail: =	=

Attachment #1: Transition Plan

Specify the transition plan for the=20 waiver:

Character Count: = out of 12000

=20

Additional Needed Information (Optional)

Provide additional needed = information for=20 the waiver (optional):

Character = Count: out of 60000

=20

Appendix A: Waiver Administration and Operation

State Line of Authority for Waiver=20 Operation. Specify the state line of authority for the = operation of=20 the waiver (select one):

The waiver is operated by the = State=20 Medicaid agency.

Specify the Medicaid agency division/unit that = has line=20 authority for the operation of the waiver program (select = one):

The Medical Assistance = Unit.

Specify the unit = name:=20 =20 (Do not complete item A-2) =

Another division/unit within the = State=20 Medicaid agency that is separate from the Medical Assistance=20 Unit.

Specify the division/unit = name. This=20 includes administrations/divisions under the umbrella agency that has = been=20 identified as the Single State Medicaid Agency. =20 (Complete item A-2-a).

not selected

The waiver is operated by a = separate agency=20 of the State that is not a division/unit of the Medicaid = agency.

Specify the division/unit=20 name: =20
In accordance with 42 CFR =A7431.10, the = Medicaid agency=20 exercises administrative discretion in the administration and = supervision of=20 the waiver and issues policies, rules and regulations related to the = waiver.=20 The interagency agreement or memorandum of understanding that sets = forth the=20 authority and arrangements for this policy is available through the = Medicaid=20 agency to CMS upon request. (Complete item A-2-b).

not = selected

Appendix A: Waiver Administration and Operation

Oversight of=20 Performance.
1. Medicaid Director Oversight of = Performance=20 When the Waiver is Operated by another Division/Unit within the = State=20 Medicaid Agency. When = the waiver=20 is operated by another division/administration within the umbrella = agency=20 designated as the Single State Medicaid Agency. Specify (a) the = functions=20 performed by that division/administration (i.e., the Developmental=20 Disabilities Administration within the Single State Medicaid = Agency), (b)=20 the document utilized to outline the roles and responsibilities = related to=20 waiver operation, and (c) the methods that are employed by the = designated=20 State Medicaid Director (in some instances, the head of umbrella = agency) in=20 the oversight of these activities:
  Complete=20 Appendix A-1 before completing this section.=20
  
  Character = Count:=20 out of = 12000
  
  =20
2. Medicaid Agency Oversight of = Operating=20 Agency Performance. When the = waiver is=20 not operated by the Medicaid agency, specify the functions that are=20 expressly delegated through a memorandum of understanding (MOU) or = other=20 written document, and indicate the frequency of review and update = for that=20 document. Specify the methods that the Medicaid agency uses to = ensure that=20 the operating agency performs its assigned waiver operational and=20 administrative functions in accordance with waiver requirements. = Also=20 specify the frequency of Medicaid agency assessment of operating = agency=20 performance:
  Complete Appendix A-1 before completing = this=20 section.=20
  
  Character = Count:=20 out of 12000 =
  
  =20

Appendix A: Waiver Administration and Operation

Use of Contracted Entities. = Specify=20 whether contracted entities perform waiver operational and = administrative=20 functions on behalf of the Medicaid agency and/or the operating agency = (if=20 applicable) (select one):

Yes. Contracted entities perform = waiver=20 operational and administrative functions on behalf of the Medicaid = agency=20 and/or operating agency (if applicable).

Specify the types=20 of contracted entities and briefly describe the functions that they=20 perform. Complete Items A-5 and=20 A-6.:

Character = Count:=20 out of 6000 =

=20

No. Contracted entities do not = perform=20 waiver operational and administrative functions on behalf of the = Medicaid=20 agency and/or the operating agency (if applicable).

not = selected

Appendix A: Waiver Administration and Operation

Role of Local/Regional Non-State=20 Entities. Indicate whether local or regional non-state = entities=20 perform waiver operational and administrative functions and, if so, = specify=20 the type of entity (Select One):

not selected

Not applicable

Applicable - Local/regional non-state agencies = perform=20 waiver operational and administrative functions.

Check each that applies:

Local/Regional non-state=20 public agencies perform waiver operational and=20 administrative functions at the local or regional level. There is an=20 interagency=20 agreement or memorandum of understanding between the State and these = agencies that=20 sets forth responsibilities and performance requirements for these = agencies=20 that is available through the Medicaid agency.

Specify the nature of these = agencies and=20 complete items A-5 and A-6:

Character = Count:=20 out of 6000 =

=20

Local/Regional=20 non-governmental non-state entities conduct waiver operational and = administrative functions at the local or regional level. There is a = contract=20 between the Medicaid agency and/or the operating agency (when = authorized by=20 the Medicaid agency) and each local/regional non-state entity that = sets forth=20 the responsibilities and performance requirements of the = local/regional=20 entity. The contract(s) under = which private=20 entities conduct waiver operational functions are available to CMS = upon=20 request through the Medicaid agency or the operating agency (if=20 applicable).

Specify the nature of these = entities and=20 complete items A-5 and A-6:

Character = Count:=20 out of 6000 =

=20

Not applicable - = Local/regional=20 non-state agencies do not perform waiver operational and = administrative=20 functions.

Appendix A: Waiver Administration and Operation

Responsibility for Assessment of = Performance of=20 Contracted and/or Local/Regional Non-State Entities. Specify the state agency or = agencies=20 responsible for assessing the performance of contracted and/or = local/regional=20 non-state entities in conducting waiver operational and administrative = functions:
Please complete Appendix A-3 and A-4 = before=20 completing this section=20

Character = Count:=20 out of 6000 =

=20

Appendix A: Waiver Administration and Operation

Assessment Methods and Frequency. = Describe the methods that are = used to=20 assess the performance of contracted and/or local/regional non-state = entities=20 to ensure that they perform assigned waiver operational and = administrative=20 functions in accordance with waiver requirements. Also specify how = frequently=20 the performance of contracted and/or local/regional non-state entities = is=20 assessed:
Please complete Appendix A-3 and A-4 = before=20 completing this section=20

Character = Count:=20 out of 6000 =

=20

Appendix A: Waiver Administration and Operation

Distribution of Waiver = Operational=20 and Administrative Functions. In the = following=20 table, specify the entity or entities that have responsibility for = conducting=20 each of the waiver operational and administrative functions listed = (check=20 each that applies):

In accordance with = 42 CFR=20 =A7431.10, when the Medicaid agency does not directly conduct a = function, it=20 supervises the performance of the function and establishes and/or = approves=20 policies that affect the function. All=20 functions not performed directly by the Medicaid agency must be = delegated in=20 writing and monitored by the Medicaid Agency. Note: More than one box may be checked per = item.=20 Ensure that Medicaid is checked when the Single State Medicaid Agency = (1)=20 conducts the function directly; (2) supervises the delegated function; = and/or=20 (3) establishes and/or approves policies related to the = function.=20

Function	Medicaid=20 Agency
Participant waiver=20 enrollment
Waiver = enrollment=20 managed against approved limits
Waiver = expenditures=20 managed against approved levels
Level of = care=20 evaluation
Review of = Participant=20 service plans
Prior = authorization of=20 waiver services
Utilization=20 management
Qualified = provider=20 enrollment
Execution = of Medicaid=20 provider agreements
Establishment of a=20 statewide rate methodology
Rules, = policies,=20 procedures and information development governing the waiver=20 program
Quality = assurance and=20 quality improvement activities

Appendix A: Waiver Administration and Operation

Quality Improvement: Administrative Authority of = the Single=20 State Medicaid Agency

As a distinct = component of=20 the State=92s quality improvement strategy, provide information in the = following=20 fields to detail the State=92s methods for discovery and remediation.=20

Methods for Discovery: = Administrative Authority

The Medicaid = Agency retains=20 ultimate administrative authority and responsibility for the operation = of the=20 waiver program by exercising oversight of the performance of waiver = functions=20 by other state and local/regional non-state agencies (if appropriate) = and=20 contracted entities.
1. Performance Measures
  
  For each performance=20 measure/indicator the State will use to assess compliance with the = statutory=20 assurance complete the following. Where possible, include=20 numerator/denominator. Each performance measure must be specific to = this=20 waiver (i.e., data presented must be waiver specific).
  
  For each = performance measure,=20 provide information on the aggregated data that will enable the = State to=20 analyze and assess progress toward the performance measure. In this = section=20 provide information on the method by which each source of data is = analyzed=20 statistically/deductively or inductively, how themes are identified = or=20 conclusions drawn, and how recommendations are formulated, where=20 appropriate.
2. If applicable, in the textbox = below=20 provide any necessary additional information on the strategies = employed by=20 the State to discover/identify problems/issues within the waiver = program,=20 including frequency and parties responsible.
  
  Character = Count:=20 out of 6000 =
  
  =20

Methods for = Remediation/Fixing=20 Individual Problems

Describe the State=92s method = for addressing=20 individual problems as they are discovered. Include information = regarding=20 responsible parties and GENERAL methods for problem correction. In = addition,=20 provide information on the methods used by the State to document = these=20 items.

Character = Count: out of 6000 =

=20

Remediation Data=20 Aggregation

Remediation-related Data Aggregation = and=20 Analysis (including trend identification)=20

Responsible=20 Party (check=20 each that applies):	Frequency of=20 data aggregation and analysis (check each that applies): =
State = Medicaid=20 Agency	Weekly=20
Operating=20 Agency	Monthly =
Sub-State=20 Entity	Quarterly =
Other=20 Specify: = =20	Annually =
	Continuously and=20 Ongoing
	Other=20 Specify: = =20

Timelines

When the State does not have all = elements of=20 the Quality Improvement Strategy in place, provide timelines to design = methods=20 for discovery and remediation related to the assurance of Financial=20 Accountability that are currently non-operational.=20

No

Yes

not = selected

Please = provide a=20 detailed strategy for assuring Administrative Authority, the specific = timeline=20 for implementing identified strategies, and the parties responsible = for its=20 operation.=20

Character = Count: out of 6000 =

=20

Appendix B: Participant Access and Eligibility

B-1: Specification of the Waiver Target = Group(s)

Target Group(s). Under the = waiver of=20 Section 1902(a)(10)(B) of the Act, the State limits waiver services to = a group=20 or subgroups of individuals. Please see the instruction manual for = specifics=20 regarding age limits. In accordance with 42 CFR =A7441.301(b)(6), = select one=20 waiver target group, check each of the subgroups in the selected = target group=20 that may receive services under the waiver, and specify the minimum = and=20 maximum (if any) age of individuals served in each = subgroup:

Target Group	Included	Target SubGroup	Maximum Age
Maximum Age Limit	No Maximum Age Limit
Aged or Disabled, or Both - = General
		Aged
		Disabled (Physical)
		Disabled (Other)
Aged or Disabled, or Both - = Specific=20 Recognized Subgroups
		Brain Injury
		HIV/AIDS	=20
		Medically Fragile
		Technology Dependent
Mental Retardation or = Developmental=20 Disability, or Both
		Autism
		Developmental Disability
		Mental Retardation
Mental = Illness
		Mental Illness	=
		Serious Emotional Disturbance
not=20 selected

Additional Criteria. The State = further=20 specifies its target group(s) as follows:

Character = Count: out of 12000 =

=20

Transition of Individuals = Affected by=20 Maximum Age Limitation. When there is a maximum age limit = that=20 applies to individuals who may be served in the waiver, describe the=20 transition planning procedures that are undertaken on behalf of = participants=20 affected by the age limit (select one):

Not applicable. There = is no=20 maximum age limit

The following transition = planning=20 procedures are employed for participants who will reach the = waiver's=20 maximum age limit.

Specify:

Character = Count:=20 out of 12000 =

=20

Appendix B: Participant Access and Eligibility

B-2: Individual Cost Limit (1 of=20 2)

Individual Cost Limit. The = following=20 individual cost limit applies when determining whether to deny home = and=20 community-based services or entrance to the waiver to an otherwise = eligible=20 individual (select one) Please note that a State may have = only ONE=20 individual cost limit for the purposes of determining eligibility for = the=20 waiver:

No Cost Limit. The State does not apply an individual cost = limit. Do=20 not complete Item B-2-b or item B-2-c.

Cost Limit in Excess of = Institutional=20 Costs. The State refuses entrance = to the=20 waiver to any otherwise eligible individual when the State reasonably = expects=20 that the cost of the home and community-based services furnished to = that=20 individual would exceed the cost of a level of care specified for the = waiver=20 up to an amount specified by the State. Complete Items B-2-b and=20 B-2-c.

The limit specified by the State = is=20 (select one)

A level higher than 100% of = the=20 institutional average.

Specify the = percentage:=20

Other

Specify:

Character = Count:=20 out of 6000 =

=20

not = selected

Institutional Cost Limit. = Pursuant to 42 CFR 441.301(a)(3), the State = refuses=20 entrance to the waiver to any otherwise eligible individual when the = State=20 reasonably expects that the cost of the home and community-based = services=20 furnished to that individual would exceed 100% of the cost of the = level of=20 care specified for the waiver. Complete Items B-2-b and = B-2-c.=20

Cost Limit Lower Than Institutional = Costs. The State refuses entrance = to the=20 waiver to any otherwise qualified individual when the State reasonably = expects=20 that the cost of home and community-based services furnished to that=20 individual would exceed the following amount specified by the State = that is=20 less than the cost of a level of care specified for the waiver. =

Specify the basis=20 of the limit, including evidence that the limit is sufficient to = assure the=20 health and welfare of waiver participants. Complete Items B-2-b and=20 B-2-c.

Character = Count:=20 out of 6000 =

=20

The cost limit specified by the State=20 is (select one):

The following dollar = amount:=20

Specify = dollar=20 amount: =20

The dollar amount (select = one)=20

Is adjusted each year that the = waiver is=20 in effect by applying the following formula:

Specify the = formula:

Character = Count:=20 out of 6000 =

=20

May be adjusted during the = period the=20 waiver is in effect. The State will submit a waiver amendment to CMS = to adjust=20 the dollar amount.

not=20 selected

The following percentage that = is less=20 than 100% of the institutional average:

Specify percent: =

Other:

Specify:

Character = Count:=20 out of 6000 =

=20

not = selected

not = selected

Appendix B: Participant Access and Eligibility

B-2: Individual Cost Limit (2 of=20 2)

Please complete Appendix B-2-a before = completing=20 this section.

Method of Implementation of the = Individual=20 Cost Limit. When an individual cost limit is = specified=20 in Item B-2-a, specify the procedures that are followed to determine = in=20 advance of waiver entrance that the individual's health and welfare = can be=20 assured within the cost limit:

Character = Count: out of 12000 =

=20
Participant Safeguards. = When the=20 State specifies an individual cost limit in Item B-2-a and there is a = change=20 in the participant's condition or circumstances post-entrance to the = waiver=20 that requires the provision of services in an amount that exceeds the = cost=20 limit in order to assure the participant's health and welfare, the = State has=20 established the following safeguards to avoid an adverse impact on the = participant (check each that applies):

The participant = is referred=20 to another waiver that can accommodate the individual's = needs.=20

Additional = services in=20 excess of the individual cost limit may be authorized. =

Specify = the=20 procedures for authorizing additional services, including the amount = that may=20 be authorized:

Character = Count:=20 out of = 12000

=20

Other=20 safeguard(s)

Specify:

Character = Count:=20 out of 12000 =

=20

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (1 of=20 4)

Unduplicated Number of = Participants.=20 The following table specifies the maximum number of unduplicated = participants=20 who are served in each year that the waiver is in effect. The State = will=20 submit a waiver amendment to CMS to modify the number of participants=20 specified for any year(s), including when a modification is necessary = due to=20 legislative appropriation or another reason. The number of = unduplicated=20 participants specified in this table is basis for the cost-neutrality=20 calculations in Appendix J:

Table: B-3-a

Waiver Year Unduplicated Number of = Participants

Year 1

Year 2

Year 3

Table: B-3-a
Waiver Year	Unduplicated Number of = Participants
Year 1
Year 2
Year 3

Limitation on the Number of = Participants=20 Served at Any Point in Time. Consistent with the unduplicated = number=20 of participants specified in Item B-3-a, the State may limit to a = lesser=20 number the number of participants who will be served at any point in = time=20 during a waiver year. Indicate whether the State limits the number of=20 participants in this way: (select one):

The State does not limit the number = of=20 participants that it serves at any point in time during a waiver = year.

The State limits the number of = participants=20 that it serves at any point in time during a waiver=20 year.

The=20 limit that applies to each year of the waiver period is specified in = the=20 following table:

Table: B-3-b
Waiver Year	Maximum Number of Participants Served At Any Point = During=20 the Year
Year 1
Year 2
Year 3	=20

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (2 of=20 4)

Reserved Waiver Capacity. = The State=20 may reserve a portion of the participant capacity of the waiver for = specified=20 purposes (e.g., provide for the community transition of = institutionalized=20 persons or furnish waiver services to individuals experiencing a = crisis)=20 subject to CMS review and approval. The State (select one): =

Not applicable. The state does = not reserve=20 capacity.

The State reserves capacity for = the=20 following = purpose(s).

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (3 of=20 4)

Scheduled Phase-In or = Phase-Out.=20 Within a waiver year, the State may make the number of participants = who are=20 served subject to a phase-in or phase-out schedule (select = one):=20

The waiver is not = subject to a=20 phase-in or a phase-out schedule.

The waiver is subject = to a phase-in=20 or phase-out schedule that is included in Attachment #1 to = Appendix B-3.=20 This schedule constitutes an intra-year limitation on the number = of=20 participants who are served in the = waiver.

Allocation of Waiver = Capacity.=20
Select one:

Waiver capacity is = allocated/managed on=20 a statewide basis.

Waiver capacity is allocated = to=20 local/regional non-state = entities.

Specify: (a) the entities to = which waiver=20 capacity is allocated; (b) the methodology that is used to allocate = capacity=20 and how often the methodology is reevaluated; and, (c) policies for = the=20 reallocation of unused capacity among local/regional non-state=20 entities:

Character = Count:=20 out of 12000 =

=20
Selection of Entrants to the = Waiver.=20 Specify the policies that apply to = the=20 selection of individuals for entrance to the waiver: =

Character = Count: out of 12000 =

=20

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served - Attachment #1 = (4 of 4)

Please complete Appendix B-3-d = before=20 completing this section.

Appendix B: Participant Access and Eligibility

B-4: Eligibility Groups Served in the Waiver

Note: Complete this section prior to = starting=20 B-5: Post-Eligibility Treatment of Income

1. State Classification. The = State is=20 a (select one):
  
  =A71634 State
  
  SSI Criteria State
  
  209(b) State
  
  not selected
2. Miller = Trust=20 State.
  
  Indicate whether the State is a Miller = Trust State=20 (select one):
  
  No
  
  Yes
  
  Unknown
Medicaid Eligibility Groups Served = in the=20 Waiver. Individuals who receive services under this waiver = are=20 eligible under the following eligibility groups contained in the State = plan.=20 The State applies all applicable federal financial participation = limits under=20 the plan. Check all that apply:

Eligibility Groups = Served in=20 the Waiver (excluding the special home and community-based waiver = group under=20 42 CFR =A7435.217)

Low income = families with=20 children as provided in =A71931 of the Act

SSI=20 recipients

=20 Aged, blind or disabled in 209(b) = states who are=20 eligible under 42 CFR =A7435.121

Optional State = supplement=20 recipients

Optional = categorically needy=20 aged and/or disabled individuals who have income at: =

Select one:

100% of the Federal poverty = level=20 (FPL)

% of FPL, which is lower than = 100% of=20 FPL.

Specify = percentage:=20

not = selected

Working = individuals with=20 disabilities who buy into Medicaid (BBA working disabled group as = provided in=20 =A71902(a)(10)(A)(ii)(XIII)) of the Act)

Working = individuals with=20 disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as = provided in=20 =A71902(a)(10)(A)(ii)(XV) of the Act)

Working = individuals=20 with disabilities who buy into Medicaid (TWWIIA Medical Improvement = Coverage=20 Group as provided in =A71902(a)(10)(A)(ii)(XVI) of the = Act)=20

Disabled = individuals=20 age 18 or younger who would require an institutional level of care = (TEFRA 134=20 eligibility group as provided in =A71902(e)(3) of the = Act)

Medically=20 needy

Medically = needy in 209(b)=20 States (42 CFR =A7435.330)

Medically = needy in 1634=20 States and SSI Criteria States (42 CFR =A7435.320, =A7435.322 and=20 =A7435.324)

Other specified groups (include only=20 statutory/regulatory reference to reflect the additional groups in the = State=20 plan that may receive services under this waiver) =

Specify:

Character = Count: out of 6000 =

=20

Special home and=20 community-based waiver group under 42 CFR =A7435.217) Note: = When the=20 special home and community-based waiver group under 42 CFR =A7435.217 = is=20 included, Appendix B-5 must be completed

No. The State does not furnish waiver = services to=20 individuals in the special home and community-based waiver group under = 42 CFR=20 =A7435.217. Appendix B-5 is not submitted. =

Yes. The State furnishes waiver services to = individuals=20 in the special home and community-based waiver group under 42 CFR=20 =A7435.217.

not = selected

Select one and complete Appendix=20 B-5.

All individuals in the special = home and=20 community-based waiver group under 42 CFR =A7435.217

Only the following groups of = individuals=20 in the special home and community-based waiver group under 42 CFR=20 =A7435.217

not selected

Check each that applies:

A special = income level=20 equal to:

Select one:

300% of the SSI Federal = Benefit Rate=20 (FBR)

A percentage of FBR, which is = lower=20 than 300% (42 CFR =A7435.236)

Specify percentage:=20

A dollar amount which is = lower than=20 300%.

Specify dollar amount:=20

not = selected

Aged, blind and = disabled=20 individuals who meet requirements that are more restrictive than the = SSI=20 program (42 CFR =A7435.121)

Medically = needy without=20 spenddown in States which also provide Medicaid to recipients of SSI = (42 CFR=20 =A7435.320, =A7435.322 and =A7435.324)

Medically = needy without=20 spend down in 209(b) States (42 CFR =A7435.330)

Aged and disabled individuals who = have income=20 at:

Select one:

100% of FPL

% of FPL, which is lower = than=20 100%.

Specify percentage=20 amount: =20

not = selected

Other specified = groups=20 (include only statutory/regulatory reference to reflect the additional = groups=20 in the State plan that may receive services under this = waiver)=20

Specify:

Character = Count:=20 out of 6000 =

=20

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (1 of 4)

In accordance with 42 CFR =A7441.303(e), = Appendix B-5=20 must be completed when the State furnishes waiver services to = individuals in the=20 special home and community-based waiver group under 42 CFR =A7435.217, = as=20 indicated in Appendix B-4. Post-eligibility applies only to the 42 CFR = =A7435.217=20 group. A State that uses spousal impoverishment rules under =A71924 of = the Act to=20 determine the eligibility of individuals with a community spouse may = elect to=20 use spousal post-eligibility rules under =A71924 of the Act to protect a = personal=20 needs allowance for a participant with a community spouse.

Use of Spousal Impoverishment = Rules.=20 Indicate whether spousal impoverishment rules are used to determine=20 eligibility for the special home and community-based waiver group = under 42 CFR=20 =A7435.217 (select one):

Please complete Appendix B-4 before = completing=20 this section

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (2 of 4)

Regular Post-Eligibility Treatment of = Income:=20 SSI State.

Please complete Appendix B-5a before = completing=20 this section

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (3 of 4)

Regular Post-Eligibility Treatment of = Income:=20 209(B) State.

Please complete Appendix B-5a before = completing=20 this section

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (4 of 4)

Post-Eligibility = Treatment of=20 Income Using Spousal Impoverishment Rules

The State=20 uses the post-eligibility rules of =A71924(d) of the Act (spousal = impoverishment=20 protection) to determine the contribution of a participant with a = community=20 spouse toward the cost of home and community-based care if it = determines the=20 individual's eligibility under =A71924 of the Act. There is deducted = from the=20 participant=92s monthly income a personal needs allowance (as = specified below),=20 a community spouse's allowance and a family allowance as specified in = the=20 State Medicaid Plan.. The State must also protect amounts for incurred = expenses for medical or remedial care (as specified below). =

Please complete Appendix B-5a before completing = this=20 section

Appendix B: Participant Access and Eligibility

B-6: Evaluation/Reevaluation of Level of Care

As specified in 42 CFR =A7441.302(c), the = State=20 provides for an evaluation (and periodic reevaluations) of the need for = the=20 level(s) of care specified for this waiver, when there is a reasonable=20 indication that an individual may need such services in the near future = (one=20 month or less), but for the availability of home and community-based = waiver=20 services.

Reasonable Indication of Need for=20 Services. In order for an individual to be determined to need = waiver=20 services, an individual must require: (a) the provision of at least = one waiver=20 service, as documented in the service plan, and (b) the = provision of=20 waiver services at least monthly or, if the need for services is less = than=20 monthly, the participant requires regular monthly monitoring which = must be=20 documented in the service plan. Specify the State's policies = concerning the=20 reasonable indication of the need for services:
1. Minimum number of services.
  
  The minimum number of waiver = services=20 (one or more) that an individual must require in order to be = determined to=20 need waiver services is: =20
2. Frequency of services. The State requires (select one):
  
  The provision of waiver = services at=20 least monthly
  
  Monthly monitoring of the = individual=20 when services are furnished on a less than monthly = basis
  
  If the State also requires a = minimum=20 frequency for the provision of waiver services other than monthly = (e.g.,=20 quarterly), specify the frequency:
  
  Character = Count:=20 out of 4000 =
  
  =20
  
  not = selected
Responsibility for Performing = Evaluations and=20 Reevaluations. Level of care evaluations and reevaluations = are=20 performed (select one):

Directly by the Medicaid = agency=20

By the operating agency = specified in=20 Appendix A

By an entity under contract = with the=20 Medicaid agency.

Specify the = entity:=20

Character = Count:=20 out of 4000 =

=20

Other

Specify:=20

Character=20 Count: out of = 4000

=20

not selected
Qualifications of Individuals = Performing=20 Initial Evaluation: Per 42 = CFR=20 =A7441.303(c)(1), specify the educational/professional qualifications = of=20 individuals who perform the initial evaluation of level of care for = waiver=20 applicants:=20

Character = Count:=20 out of 6000 =

=20
Level of Care Criteria. = Fully specify the level of care = criteria=20 that are used to evaluate and reevaluate whether an individual needs = services=20 through the waiver and that serve as the basis of the State's level of = care=20 instrument/tool. Specify the level of care instrument/tool that is = employed.=20 State laws, regulations, and policies concerning level of care = criteria and=20 the level of care instrument/tool are available to CMS upon request = through=20 the Medicaid agency or the operating agency (if applicable), including = the=20 instrument/tool utilized.=20

Character = Count:=20 out of 12000 =

=20
Level of Care = Instrument(s). Per 42=20 CFR =A7441.303(c)(2), indicate whether the instrument/tool used to = evaluate=20 level of care for the waiver differs from the instrument/tool used to = evaluate=20 institutional level of care (select one):

The same instrument is used = in=20 determining the level of care for the waiver and for institutional = care under=20 the State Plan.

A different instrument is = used to=20 determine the level of care for the waiver than for institutional care = under=20 the State plan.

Describe how and why this = instrument=20 differs from the form used to evaluate institutional level of care and = explain=20 how the outcome of the determination is reliable, valid, and fully=20 comparable.

Character=20 Count: out of = 12000

=20

not selected
Process for Level of Care=20 Evaluation/Reevaluation: Per 42 CFR = =A7441.303(c)(1),=20 describe the process for evaluating waiver applicants for their need = for the=20 level of care under the waiver. If the reevaluation process differs = from the=20 evaluation process, describe the differences:=20

Character = Count: out of 12000 =

=20
Reevaluation Schedule. Per = 42 CFR=20 =A7441.303(c)(4), reevaluations of the level of care required by a = participant=20 are conducted no less frequently than annually according to the = following=20 schedule (select one):

Every three = months

Every six months

Every twelve months =

Other schedule

Specify the=20 other schedule:=20

Character = Count:=20 out of 4000 =

=20

not selected
Qualifications of Individuals Who = Perform=20 Reevaluations. Specify the qualifications of individuals who = perform=20 reevaluations (select one):

The qualifications of = individuals=20 who perform reevaluations are the same as individuals who perform = initial=20 evaluations.

The qualifications are=20 different.

Specify the=20 qualifications:=20

Character=20 Count: out of = 6000=20

=20

not = selected
Procedures to Ensure Timely=20 Reevaluations. Per 42 CFR =A7441.303(c)(4), = specify the=20 procedures that the State employs to ensure timely reevaluations of = level of=20 care (specify):=20

Character = Count: out of 6000

=20
Maintenance of = Evaluation/Reevaluation=20 Records. Per 42 CFR =A7441.303(c)(3), the = State assures=20 that written and/or electronically retrievable documentation of all=20 evaluations and reevaluations are maintained for a minimum period of 3 = years=20 as required in 45 CFR =A792.42. Specify the location(s) where records = of=20 evaluations and reevaluations of level of care are = maintained:=20

Character = Count: out of 6000 =

=20

Appendix B: Evaluation/Reevaluation of Level of = Care

Quality Improvement: Level of Care

As a distinct = component of=20 the State=92s quality improvement strategy, provide information in the = following=20 fields to detail the State=92s methods for discovery and remediation.=20

Methods for Discovery: = Level of=20 Care Assurance/Sub-assurances
1. Sub-Assurances:
  1. Sub-assurance: An=20 evaluation for LOC is provided to all applicants for whom there is = reasonable indication that services may be needed in the = future.=20
    
    Performance = Measures
    
    For=20 each performance measure/indicator the State will use to assess = compliance=20 with the statutory assurance complete the following. Where = possible,=20 include numerator/denominator. Each performance measure must be = specific=20 to this waiver (i.e., data presented must be waiver = specific).
    
    For each performance measure, provide=20 information on the aggregated data that will enable the State to = analyze=20 and assess progress toward the performance measure. In this = section=20 provide information on the method by which each source of data is = analyzed=20 statistically/deductively or inductively, how themes are = identified or=20 conclusions drawn, and how recommendations are formulated, where=20 appropriate.
  2. Sub-assurance: The=20 levels of care of enrolled participants are reevaluated at least = annually=20 or as specified in the approved waiver.
    
    Performance = Measures
    
    For=20 each performance measure/indicator the State will use to assess = compliance=20 with the statutory assurance complete the following. Where = possible,=20 include numerator/denominator. Each performance measure must be = specific=20 to this waiver (i.e., data presented must be waiver = specific).
    
    For each performance measure, provide=20 information on the aggregated data that will enable the State to = analyze=20 and assess progress toward the performance measure. In this = section=20 provide information on the method by which each source of data is = analyzed=20 statistically/deductively or inductively, how themes are = identified or=20 conclusions drawn, and how recommendations are formulated, where=20 appropriate.
  3. Sub-assurance: The=20 processes and instruments described in the approved waiver are = applied=20 appropriately and according to the approved description to = determine=20 participant level of care.
    
    Performance = Measures
    
    For=20 each performance measure/indicator the State will use to assess = compliance=20 with the statutory assurance complete the following. Where = possible,=20 include numerator/denominator. Each performance measure must be = specific=20 to this waiver (i.e., data presented must be waiver = specific).
    
    For each performance measure, provide=20 information on the aggregated data that will enable the State to = analyze=20 and assess progress toward the performance measure. In this = section=20 provide information on the method by which each source of data is = analyzed=20 statistically/deductively or inductively, how themes are = identified or=20 conclusions drawn, and how recommendations are formulated, where=20 appropriate.
2. If = applicable, in the=20 textbox below provide any necessary additional information on the = strategies=20 employed by the State to discover/identify problems/issues within = the waiver=20 program, including frequency and parties responsible. =
  
  Character = Count:=20 out of 6000 =
  
  =20

Methods for = Remediation/Fixing=20 Individual Problems

Describe the State=92s method = for=20 addressing individual problems as they are discovered. Include = information=20 regarding responsible parties and GENERAL methods for problem = correction. In=20 addition, provide information on the methods used by the State to = document=20 these items.

Character = Count:=20 out of 6000 =

=20

Remediation Data=20 Aggregation

Remediation-related Data Aggregation = and=20 Analysis (including trend identification)=20

Responsible=20 Party (check=20 each that applies):	Frequency of=20 data aggregation and analysis (check each that applies): =
State = Medicaid=20 Agency	Weekly =
Operating=20 Agency	Monthly =
Sub-State=20 Entity	Quarterly =
Other = Specify: =20	Annually =
	Continuously and=20 Ongoing
	Other=20 Specify: = =20

Timelines

When the State does not have all = elements of=20 the Quality Improvement Strategy in place, provide timelines to design = methods=20 for discovery and remediation related to the assurance of Financial=20 Accountability that are currently non-operational.=20

No

Yes

not = selected

Please = provide a=20 detailed strategy for assuring Administrative Authority, the specific = timeline=20 for implementing identified strategies, and the parties responsible = for its=20 operation.=20

Character = Count:=20 out of 6000 =

=20

Appendix B: Participant Access and Eligibility

B-7: Freedom of Choice

Freedom of Choice. As = provided in=20 42 CFR =A7441.302(d), when an individual is determined to be likely to = require a=20 level of care for this waiver, the individual or his or her legal = representative=20 is:=20

informed of any feasible alternatives under the waiver; and=20
given the choice of either institutional or home and = community-based=20 services.

Procedures. Specify the State's procedures for = informing=20 eligible individuals (or their legal representatives) of the feasible=20 alternatives available under the waiver and allowing these individuals = to=20 choose either institutional or waiver services. Identify the form(s) = that are=20 employed to document freedom of choice. The form or forms are = available to CMS=20 upon request through the Medicaid agency or the operating agency (if=20 applicable).

Character Count: = out of 12000

=20
Maintenance of Forms. = Per 45 CFR =A792.42, written = copies or=20 electronically retrievable facsimiles of Freedom of Choice forms are=20 maintained for a minimum of three years. Specify the locations where = copies of=20 these forms are maintained.

Character Count: = out of 4000 =

=20

Appendix B: Participant Access and Eligibility

B-8: Access to Services by Limited English = Proficiency=20 Persons

Access to Services by Limited English = Proficient=20 Persons. Specify the methods that the = State uses to=20 provide meaningful access to the waiver by Limited English Proficient = persons in=20 accordance with the Department of Health and Human Services "Guidance = to Federal=20 Financial Assistance Recipients Regarding Title VI Prohibition Against = National=20 Origin Discrimination Affecting Limited English Proficient = Persons" (68 FR = 47311 - August=20 8, 2003):

Character = Count:=20 out of 12000 =

=20

Appendix C: Participant Services

C-1: Summary of Services Covered (1 of=20 2)

Waiver Services Summary. = List the=20 services that are furnished under the waiver in the following table. = If case=20 management is not a service under the waiver, complete items C-1-b and = C-1-c:

Service=20 Type Service

Appendix C: Participant Services

C-1: Summary of Services Covered (2 of=20 2)

Provision of Case Management = Services to=20 Waiver Participants. Indicate how case management is = furnished to=20 waiver participants (select one):

not selected

Not applicable - Case management is not furnished as a distinct = activity=20 to waiver participants.

Applicable -=20 Case management is furnished as a distinct activity to waiver=20 participants.

Check each that applies:

As a waiver = service=20 defined in Appendix C-3. Do not=20 complete item C-1-c.

As a Medicaid = State plan=20 service under =A71915(i) of the Act (HCBS as a State Plan=20 Option). Complete item=20 C-1-c.

As a Medicaid = State plan=20 service under =A71915(g)(1) of the Act (Targeted Case=20 Management). Complete = item=20 C-1-c.

As an = administrative=20 activity. Complete item = C-1-c.=20 NOTE: Pursuant to CMS-2237-IFC this = selection is no=20 longer available for 1915(c) waivers.

Not applicable = - Case=20 management is not furnished as a distinct activity to waiver=20 participants. Do not = complete=20 item C-1-c.

None of the above apply = - Case management is furnished as a waiver = service (Do not=20 complete item C-1-c).
Delivery of Case Management Services. Specify the entity or entities = that conduct=20 case management functions on behalf of waiver = participants:=20

Character = Count: out of 4000

=20

Appendix C: Participant Services

C-2: General Service Specifications (1=20 of 3)

Criminal History and/or Background=20 Investigations. Specify the = State's=20 policies concerning the conduct of criminal history and/or background=20 investigations of individuals who provide waiver services (select=20 one):

No. Criminal history and/or = background=20 investigations are not required.

Yes. Criminal history and/or = background=20 investigations are required.

Specify: (a) the types of = positions (e.g.,=20 personal assistants, attendants) for which such investigations must be = conducted; (b) the scope of such investigations (e.g., state, = national); and,=20 (c) the process for ensuring that mandatory investigations have been=20 conducted. State laws, regulations and policies referenced in this = description=20 are available to CMS upon request through the Medicaid or the = operating agency=20 (if applicable):

Character = Count: out of 12000 =

=20

Abuse Registry Screening. = Specify whether the State = requires the=20 screening of individuals who provide waiver services through a=20 State-maintained abuse registry (select one): =

No. The State does not conduct = abuse=20 registry screening.

Yes. The State maintains an = abuse registry=20 and requires the screening of individuals through this=20 registry.

Specify: (a) the=20 entity (entities) responsible for maintaining the abuse registry; (b) = the=20 types of positions for which abuse registry screenings must be = conducted; and,=20 (c) the process for ensuring that mandatory screenings have been = conducted.=20 State laws, regulations and policies referenced in this description = are=20 available to CMS upon request through the Medicaid agency or the = operating=20 agency (if applicable):

Character = Count:=20 out of 12000 =

=20

Appendix C: Participant Services

C-2: General Service Specifications (2=20 of 3)

Services in=20 Facilities Subject to =A71616(e) of the Social Security Act. = Select = one:=20

No. Home and community-based = services under=20 this waiver are not provided in facilities subject to =A71616(e) = of the=20 Act.

Yes. Home and community-based = services are=20 provided in facilities subject to =A71616(e) of the Act. The = standards=20 that apply to each type of facility where waiver services are = provided=20 are available to CMS upon request through the Medicaid agency or = the=20 operating agency (if = applicable).

Appendix C: Participant Services

C-2: General Service Specifications (3=20 of 3)

Provision of Personal Care or Similar = Services=20 by Legally Responsible Individuals. A legally responsible = individual=20 is any person who has a duty under State law to care for another = person and=20 typically includes: (a) the parent (biological or adoptive) of a minor = child=20 or the guardian of a minor child who must provide care to the child or = (b) a=20 spouse of a waiver participant. Except at the option of the State and = under=20 extraordinary circumstances specified by the State, payment may not be = made to=20 a legally responsible individual for the provision of personal care or = similar=20 services that the legally responsible individual would ordinarily = perform or=20 be responsible to perform on behalf of a waiver participant. = Select=20 one:

No. The State does not make = payment to=20 legally responsible individuals for furnishing personal care or = similar=20 services.

Yes. The State makes payment to = legally=20 responsible individuals for furnishing personal care or similar = services when=20 they are qualified to provide the services.

Specify: (a) the legally = responsible=20 individuals who may be paid to furnish such services and the services = they may=20 provide; (b) State policies that specify the circumstances when = payment may be=20 authorized for the provision of extraordinary = care by a = legally=20 responsible individual and how the State ensures that the provision of = services by a legally responsible individual is in the best interest = of the=20 participant; and, (c) the controls that are employed to ensure that = payments=20 are made only for services rendered. Also, specify in Appendix = C-1/C-3 the=20 personal care or similar services for which payment may be made to = legally=20 responsible individuals under the State policies specified=20 here.

Character = Count:=20 out of 12000 =

=20

not selected
Other State Policies Concerning = Payment for=20 Waiver Services Furnished by Relatives/Legal Guardians. = Specify State=20 policies concerning making payment to relatives/legal guardians for = the=20 provision of waiver services over and above the policies addressed in = Item=20 C-2-d. Select one:

The State does not make payment = to=20 relatives/legal guardians for furnishing waiver = services.

The State makes payment to = relatives/legal=20 guardians under specific circumstances and only when the = relative/guardian is=20 qualified to furnish services.

Specify the specific = circumstances under=20 which payment is made, the types of relatives/legal guardians to whom = payment=20 may be made, and the services for which payment may be made. Specify = the=20 controls that are employed to ensure that payments are made only for = services=20 rendered. Also, specify in Appendix = C-1/C-3 each=20 waiver service for which payment may be made to relatives/legal=20 guardians.

Character = Count: out of 12000 =

=20

Relatives/legal guardians may be = paid for=20 providing waiver services whenever the relative/legal guardian is = qualified to=20 provide services as specified in Appendix C-1/C-3.

Specify = the=20 controls that are employed to ensure that payments are made only for = services=20 rendered.

Character = Count:=20 out of 12000 =

=20

Other policy.

Specify:

Character = Count:=20 out of 12000 =

=20

not selected
Open Enrollment of Providers. = Specify the processes that are = employed to=20 assure that all willing and qualified providers have the opportunity = to enroll=20 as waiver service providers as provided in 42 CFR = =A7431.51:

Character = Count: out of 12000

=20

Appendix C: Participant Services

Quality Improvement: Qualified Providers

As a distinct = component of=20 the State=92s quality improvement strategy, provide information in the = following=20 fields to detail the State=92s methods for discovery and remediation.=20

Methods for Discovery: = Qualified=20 Providers
1. Sub-Assurances:
  1. Sub-Assurance: The=20 State verifies that providers initially and continually meet = required=20 licensure and/or certification standards and adhere to other = standards=20 prior to their furnishing waiver services.
    
    Performance = Measures
    
    For each = performance=20 measure/indicator the State will use to assess compliance with the = statutory assurance complete the following. Where possible, = include=20 numerator/denominator. Each performance measure must be specific = to this=20 waiver (i.e., data presented must be waiver specific).
    
    For each = performance=20 measure, provide information on the aggregated data that will = enable the=20 State to analyze and assess progress toward the performance = measure. In=20 this section provide information on the method by which each = source of=20 data is analyzed statistically/deductively or inductively, how = themes are=20 identified or conclusions drawn, and how recommendations are = formulated,=20 where appropriate.
  2. Sub-Assurance: The=20 State monitors non-licensed/non-certified providers to assure = adherence to=20 waiver requirements.
    
    For each = performance=20 measure/indicator the State will use to assess compliance with the = statutory assurance complete the following. Where possible, = include=20 numerator/denominator. Each performance measure must be specific = to this=20 waiver (i.e., data presented must be waiver specific).
    
    For each = performance=20 measure, provide information on the aggregated data that will = enable the=20 State to analyze and assess progress toward the performance = measure. In=20 this section provide information on the method by which each = source of=20 data is analyzed statistically/deductively or inductively, how = themes are=20 identified or conclusions drawn, and how recommendations are = formulated,=20 where appropriate.
  3. Sub-Assurance: The=20 State implements its policies and procedures for verifying that = provider=20 training is conducted in accordance with state requirements and = the=20 approved waiver.
    
    For each = performance=20 measure/indicator the State will use to assess compliance with the = statutory assurance complete the following. Where possible, = include=20 numerator/denominator. Each performance measure must be specific = to this=20 waiver (i.e., data presented must be waiver specific).
    
    For each = performance=20 measure, provide information on the aggregated data that will = enable the=20 State to analyze and assess progress toward the performance = measure. In=20 this section provide information on the method by which each = source of=20 data is analyzed statistically/deductively or inductively, how = themes are=20 identified or conclusions drawn, and how recommendations are = formulated,=20 where appropriate.
2. If applicable, in the textbox = below=20 provide any necessary additional information on the strategies = employed by=20 the State to discover/identify problems/issues within the waiver = program,=20 including frequency and parties responsible.
  
  Character = Count:=20 out of 6000 =
  
  =20

Methods for = Remediation/Fixing=20 Individual Problems

Describe the State=92s method = for addressing=20 individual problems as they are discovered. Include information = regarding=20 responsible parties and GENERAL methods for problem correction. In = addition,=20 provide information on the methods used by the State to document = these=20 items.

Character = Count: out of 6000 =

=20

Remediation Data=20 Aggregation

Remediation-related Data Aggregation = and=20 Analysis (including trend identification)=20

Responsible=20 Party (check=20 each that applies):	Frequency of=20 data aggregation and analysis (check each that applies): =
State = Medicaid=20 Agency	Weekly=20
Operating=20 Agency	Monthly =
Sub-State=20 Entity	Quarterly =
Other=20 Specify: = =20	Annually =
	Continuously and=20 Ongoing
	Other=20 Specify: = =20

Timelines

When the State does not have all = elements of=20 the Quality Improvement Strategy in place, provide timelines to design = methods=20 for discovery and remediation related to the assurance of Financial=20 Accountability that are currently non-operational.=20

No

Yes

not = selected

Please = provide a=20 detailed strategy for assuring Administrative Authority, the specific = timeline=20 for implementing identified strategies, and the parties responsible = for its=20 operation.=20

Character = Count: out of 6000 =

=20

Appendix C: Participant Services

C-3: Waiver Services Specifications

Section C-3 'Service Specifications' is = incorporated into=20 Section C-1 'Waiver Services.'

Appendix C: Participant Services

C-4: Additional Limits on Amount of Waiver = Services

Additional Limits on Amount of Waiver=20 Services. Indicate whether the waiver employs any of the = following=20 additional limits on the amount of waiver services (select = one).

not selected

Not applicable - The State = does not=20 impose a limit on the amount of waiver services except as provided in = Appendix=20 C-3.

Applicable - The State imposes additional = limits on the=20 amount of waiver services.

When a limit is employed, specify: (a) the = waiver=20 services to which the limit applies; (b) the basis of the limit, = including its=20 basis in historical expenditure/utilization patterns and, as = applicable, the=20 processes and methodologies that are used to determine the amount of = the limit=20 to which a participant's services are subject; (c) how the limit will = be=20 adjusted over the course of the waiver period; (d) provisions for = adjusting or=20 making exceptions to the limit based on participant health and welfare = needs=20 or other factors specified by the state; (e) the safeguards that are = in effect=20 when the amount of the limit is insufficient to meet a participant's = needs;=20 (f) how participants are notified of the amount of the limit. = (check each=20 that applies)

Limit(s) on Set(s) of = Services. There is a = limit on the=20 maximum dollar amount of waiver services that is authorized for one or = more=20 sets of services offered under the waiver.

Furnish the=20 information specified above.=20

Character = Count: out of 24000 =

=20

Prospective = Individual=20 Budget Amount. There is a limit on the maximum = dollar=20 amount of waiver services authorized for each specific=20 participant.

Furnish the=20 information specified above.=20

Character = Count:=20 out of 24000 =

=20

Budget Limits by Level of=20 Support.=20 Based on an assessment process and/or other factors, participants are = assigned=20 to funding levels that are limits on the maximum dollar amount of = waiver=20 services.

Furnish the=20 information specified above.=20

Character = Count:=20 out of 24000 =

=20

Other Type of Limit. The State = employs another=20 type of limit.

Describe the limit=20 and furnish the information specified above.=20

Character = Count: out of 24000 =

=20

Not applicable. The State does not impose a limit = on the=20 amount of waiver services except as provided in Appendix = C-3.=20

Appendix D: Participant-Centered Planning and Service = Delivery

D-1: Service Plan Development (1 of=20 8)

State Participant-Centered Service Plan=20 Title: =20

Responsibility for Service Plan=20 Development. Per 42 CFR =A7441.301(b)(2), specify who is = responsible=20 for the development of the service plan and the qualifications of = these=20 individuals (select each that applies):

=20 Registered nurse, licensed to = practice in the=20 State

Licensed = practical or=20 vocational nurse, acting within the scope of practice under State=20 law

Licensed physician (M.D. or=20 D.O)

Case = Manager = (qualifications=20 specified in Appendix C-1/C-3)

Case=20 Manager (qualifications not = specified in=20 Appendix C-1/C-3).

Specify=20 qualifications:=20

Character=20 Count: out of = 6000

=20

Social Worker. =

Specify=20 qualifications:=20

Character=20 Count: out of = 6000=20

=20

Other=20

Specify the individuals = and their=20 qualifications:=20

Character = Count:=20 out of = 6000

=20

Appendix D: Participant-Centered Planning and Service = Delivery

D-1: Service Plan Development (2 of=20 8)

Service Plan Development = Safeguards.=20 Select one:=20

Entities and/or individuals = that have=20 responsibility for service plan development may not provide = other direct=20 waiver services to the participant.

Entities and/or individuals = that have=20 responsibility for service plan development may provide other = direct=20 waiver services to the = participant.

The = State has=20 established the following safeguards to ensure that service plan = development=20 is conducted in the best interests of the participant.=20 Specify:=20

Character = Count:=20 out of 6000 =

=20

Appendix D: Participant-Centered Planning and Service = Delivery

D-1: Service Plan Development (3 of=20 8)

Supporting the Participant in = Service Plan=20 Development. Specify: = (a) the=20 supports and information that are made available to the participant = (and/or=20 family or legal representative, as appropriate) to direct and be = actively=20 engaged in the service plan development process and (b) the = participant's=20 authority to determine who is included in the process. =

Character = Count:=20 out of 12000 =

=20

Appendix D: Participant-Centered Planning and Service = Delivery

D-1: Service Plan Development (4 of=20 8)

Service Plan Development = Process.=20 In four pages or less, describe the = process=20 that is used to develop the participant-centered service plan, = including: (a)=20 who develops the plan, who participates in the process, and the timing = of the=20 plan; (b) the types of assessments that are conducted to support the = service=20 plan development process, including securing information about = participant=20 needs, preferences and goals, and health status; (c) how the = participant is=20 informed of the services that are available under the waiver; (d) how = the plan=20 development process ensures that the service plan addresses = participant goals,=20 needs (including health care needs), and preferences; (e) how waiver = and other=20 services are coordinated; (f) how the plan development process = provides for=20 the assignment of responsibilities to implement and monitor the plan; = and, (g)=20 how and when the plan is updated, including when the participant's = needs=20 change. State laws, regulations, and policies cited that affect the = service=20 plan development process are available to CMS upon request through the = Medicaid agency or the operating agency (if = applicable):=20

Character Count: = out of 24000

=20

Appendix D: Participant-Centered Planning and Service = Delivery

D-1: Service Plan Development (5 of=20 8)

Risk Assessment and = Mitigation.=20 Specify how potential risks to the = participant are assessed during the service plan development process = and how=20 strategies to mitigate risk are incorporated into the service plan, = subject to=20 participant needs and preferences. In addition, describe how the = service plan=20 development process addresses backup plans and the arrangements that = are used=20 for backup.=20

Character = Count: out of 12000 =

=20

Appendix D: Participant-Centered Planning and Service = Delivery

D-1: Service Plan Development (6 of=20 8)

Informed Choice of = Providers. Describe how participants are = assisted in=20 obtaining information about and selecting from among qualified = providers of=20 the waiver services in the service plan.=20

Character = Count:=20 out of 6000 =

=20

Appendix D: Participant-Centered Planning and Service = Delivery

D-1: Service Plan Development (7 of=20 8)

Process for Making Service Plan = Subject to the=20 Approval of the Medicaid Agency. Describe = the process by=20 which the service plan is made subject to the approval of the Medicaid = agency=20 in accordance with 42 CFR =A7441.301(b)(1)(i):=20

Character = Count:=20 out of 6000 =

=20

Appendix D: Participant-Centered Planning and Service = Delivery

D-1: Service Plan Development (8 of=20 8)

Service Plan Review and = Update. The=20 service plan is subject to at least annual periodic review and update = to=20 assess the appropriateness and adequacy of the services as participant = needs=20 change. Specify the minimum schedule for = the review=20 and update of the service plan:=20

Every three months or more = frequently when=20 necessary

Every six months or more = frequently when=20 necessary

Every twelve months or more = frequently when=20 necessary

Other = schedule

Specify = the other=20 schedule:=20

Character = Count: out of 6000 =

=20

Maintenance of Service Plan = Forms.=20 Written copies or electronic facsimiles of service plans are = maintained for a=20 minimum period of 3 years as required by 45 CFR =A792.42. Service = plans are=20 maintained by the following (check each that applies):

Medicaid=20 agency

Operating=20 agency

Case=20 manager

Other=20

Specify:=20

Character = Count:=20 out of 4000 =

=20

Appendix D: Participant-Centered Planning and Service = Delivery

D-2: Service Plan Implementation and = Monitoring

Service Plan Implementation and=20 Monitoring. Specify: (a) the entity (entities) = responsible=20 for monitoring the implementation of the service plan and participant = health=20 and welfare; (b) the monitoring and follow-up method(s) that are used; = and,=20 (c) the frequency with which monitoring is performed.=20

Character Count: = out of 24000

=20

Monitoring Safeguards. = Select=20 one:=20

Entities and/or individuals = that have=20 responsibility to monitor service plan implementation and = participant=20 health and welfare may not provide other direct waiver services = to the=20 participant.

Entities and/or individuals = that have=20 responsibility to monitor service plan implementation and = participant=20 health and welfare may provide other direct waiver services to = the=20 participant

The State = has=20 established the following safeguards to ensure that monitoring is = conducted in=20 the best interests of the participant. Specify:=20

Character = Count:=20 out of 24000 =

=20

Appendix D: Participant-Centered Planning and Service = Delivery

Quality Improvement: Service Plan

As a distinct = component of=20 the State=92s quality improvement strategy, provide information in the = following=20 fields to detail the State=92s methods for discovery and remediation.=20

Methods for Discovery: = Service=20 Plan Assurance/Sub-assurances
1. Sub-Assurances:
  1. Sub-assurance: Service=20 plans address all participants=92 assessed needs (including health = and=20 safety risk factors) and personal goals, either by the provision = of waiver=20 services or through other means.
    
    Performance = Measures
    
    For=20 each performance measure/indicator the State will use to assess = compliance=20 with the statutory assurance complete the following. Where = possible,=20 include numerator/denominator. Each performance measure must be = specific=20 to this waiver (i.e., data presented must be waiver = specific).
    
    For each performance measure, provide=20 information on the aggregated data that will enable the State to = analyze=20 and assess progress toward the performance measure. In this = section=20 provide information on the method by which each source of data is = analyzed=20 statistically/deductively or inductively, how themes are = identified or=20 conclusions drawn, and how recommendations are formulated, where=20 appropriate.
  2. Sub-assurance: The=20 State monitors service plan development in accordance with its = policies=20 and procedures.
    
    Performance = Measures
    
    For=20 each performance measure/indicator the State will use to assess = compliance=20 with the statutory assurance complete the following. Where = possible,=20 include numerator/denominator. Each performance measure must be = specific=20 to this waiver (i.e., data presented must be waiver = specific).
    
    For each performance measure, provide=20 information on the aggregated data that will enable the State to = analyze=20 and assess progress toward the performance measure. In this = section=20 provide information on the method by which each source of data is = analyzed=20 statistically/deductively or inductively, how themes are = identified or=20 conclusions drawn, and how recommendations are formulated, where=20 appropriate.
  3. Sub-assurance: Service=20 plans are updated/revised at least annually or when warranted by = changes=20 in the waiver participant=92s needs.
    
    Performance = Measures
    
    For=20 each performance measure/indicator the State will use to assess = compliance=20 with the statutory assurance complete the following. Where = possible,=20 include numerator/denominator. Each performance measure must be = specific=20 to this waiver (i.e., data presented must be waiver = specific).
    
    For each performance measure, provide=20 information on the aggregated data that will enable the State to = analyze=20 and assess progress toward the performance measure. In this = section=20 provide information on the method by which each source of data is = analyzed=20 statistically/deductively or inductively, how themes are = identified or=20 conclusions drawn, and how recommendations are formulated, where=20 appropriate.
  4. Sub-assurance: Services=20 are delivered in accordance with the service plan, including the = type,=20 scope, amount, duration and frequency specified in the service=20 plan.
    
    Performance = Measures
    
    For=20 each performance measure/indicator the State will use to assess = compliance=20 with the statutory assurance complete the following. Where = possible,=20 include numerator/denominator. Each performance measure must be = specific=20 to this waiver (i.e., data presented must be waiver = specific).
    
    For each performance measure, provide=20 information on the aggregated data that will enable the State to = analyze=20 and assess progress toward the performance measure. In this = section=20 provide information on the method by which each source of data is = analyzed=20 statistically/deductively or inductively, how themes are = identified or=20 conclusions drawn, and how recommendations are formulated, where=20 appropriate.
  5. Sub-assurance:=20 Participants are afforded choice: Between waiver services and=20 institutional care; and between/among waiver services and=20 providers.
    
    Performance = Measures
    
    For=20 each performance measure/indicator the State will use to assess = compliance=20 with the statutory assurance complete the following. Where = possible,=20 include numerator/denominator. Each performance measure must be = specific=20 to this waiver (i.e., data presented must be waiver = specific).
    
    For each performance measure, provide=20 information on the aggregated data that will enable the State to = analyze=20 and assess progress toward the performance measure. In this = section=20 provide information on the method by which each source of data is = analyzed=20 statistically/deductively or inductively, how themes are = identified or=20 conclusions drawn, and how recommendations are formulated, where=20 appropriate.
2. If applicable, in the textbox = below=20 provide any necessary additional information on the strategies = employed by=20 the State to discover/identify problems/issues within the waiver = program,=20 including frequency and parties responsible.
  
  Character = Count:=20 out of 6000 =
  
  =20

Methods for = Remediation/Fixing=20 Individual Problems

Describe the State=92s method = for addressing=20 individual problems as they are discovered. Include information = regarding=20 responsible parties and GENERAL methods for problem correction. In = addition,=20 provide information on the methods used by the State to document = these=20 items.

Character = Count: out of 6000 =

=20

Remediation Data=20 Aggregation

Remediation-related Data Aggregation = and=20 Analysis (including trend identification)=20

Responsible=20 Party (check=20 each that applies):	Frequency of=20 data aggregation and analysis (check each that applies): =
State = Medicaid=20 Agency	Weekly=20
Operating=20 Agency	Monthly =
Sub-State=20 Entity	Quarterly =
Other=20 Specify: = =20	Annually =
	Continuously and=20 Ongoing
	Other=20 Specify: = =20

Timelines

When the State does not have all = elements of=20 the Quality Improvement Strategy in place, provide timelines to design = methods=20 for discovery and remediation related to the assurance of Financial=20 Accountability that are currently non-operational.=20

No

Yes

not = selected

Please = provide a=20 detailed strategy for assuring Administrative Authority, the specific = timeline=20 for implementing identified strategies, and the parties responsible = for its=20 operation.=20

Character = Count: out of 6000 =

=20

Appendix E: Participant Direction of Services

Applicability (from = Application=20 Section 3, Components of the Waiver Request):

Yes. This waiver provides = participant=20 direction opportunities. Complete the = remainder=20 of the Appendix.

No. This waiver does not provide = participant=20 direction opportunities. Do not = complete the=20 remainder of the Appendix.

not = selected

CMS urges states to afford all waiver=20 participants the opportunity to direct their services. Participant = direction of=20 services includes the participant exercising decision-making authority = over=20 workers who provide services, a participant-managed budget or both. CMS = will=20 confer the Independence Plus designation when the waiver evidences a = strong=20 commitment to participant direction.

Indicate whether Independence Plus = designation is=20 requested (select one):

Yes. The State requests that = this waiver=20 be considered for Independence Plus designation.

No. Independence Plus = designation is not=20 requested.

not=20 selected