Form CMS-8003 Application for a sec. 1915(c) Home and Community-Based

Home & Community Based Waiver Requests and Supporting Regulations; 42 CFR 440.180 and 441.300 - 441.310 (CMS-8003)

HCBSWaiverApp-v3 [rev Feb 2017]

Home & Community Based Waiver Requests and Supporting Regulations; 42 CFR 440.180, 441.300-.310

OMB: 0938-0449

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0449 can be found here:

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Application for a §1915 (c) HCBS Waiver
HCBS Waiver Application Version 3.5

Includes Changes Implemented through November 2014

Submitted by:

Submission Date:
CMS Receipt Date (CMS Use)

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0449
(CMS-8003). The time required to complete this information collection is estimated at 160 hours per response (for new waivers) or 75
hours per response (to renew existing applications), including the time to review instructions, search existing data resources, gather
the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Baltimore, Maryland 21244-1850.

State:
Effective Date

Application for a §1915(c) Home and Community-Based
Services Waiver
PURPOSE OF THE

HCBS WAIVER PROGRAM

The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in §1915(c) of
the Social Security Act. The program permits a State to furnish an array of home and community-based
services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. The Centers
for Medicare & Medicaid Services (CMS) recognizes that the design and operational features of a waiver
program will vary depending on the specific needs of the target population, the resources available to the State,
service delivery system structure, State goals and objectives, and other factors.

State:
Effective Date

Application: 1

Request Information

requests approval for a Medicaid home and communityA. The State of
based services (HCBS) waiver under the authority of §1915(c) of the Social Security Act (the Act).
B. Program Title (optional –
this title will be used to
locate this waiver in the
finder):
C. Type of Request: (the system will automatically populate new, amendment, or renewal)
Requested Approval Period: (For new waivers requesting five year approval periods, the waiver must
serve individuals who are dually eligible for Medicaid and Medicare.)


3 years



5 years



New to replace waiver
Replacing Waiver Number:



Migration Waiver – this is an existing approved waiver
Provide the information about the original waiver being migrated
Base Waiver Number:
Amendment Number (if
applicable):
Effective Date: (mm/dd/yy)

D. Type of Waiver (select only one):



Model Waiver



Regular Waiver

Proposed Effective Date:
Approved Effective Date (CMS Use):

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

State:
Effective Date

Hospital (select applicable level of care)
 Hospital as defined in 42 CFR §440.10
If applicable, specify whether the State additionally limits the waiver to subcategories of
the hospital level of care:

Application: 2




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

Nursing Facility (select applicable level of care)
 Nursing Facility as defined in 42 CFR §440.40 and 42 CFR §440.155
If applicable, specify whether the State additionally limits the waiver to subcategories of
the nursing facility level of care:

 Institution for Mental Disease for persons with mental illnesses aged 65 and older as
provided in 42 CFR §440.140


State:
Effective Date

Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) (as
defined in 42 CFR §440.150)
If applicable, specify whether the State additionally limits the waiver to subcategories of the
ICF/IID facility level of care:

Application: 3

G. Concurrent Operation with Other Programs. This waiver operates concurrently with another program
(or programs) approved under the following authorities
Select one:


Not applicable



Applicable

Check the applicable authority or authorities:



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

Specify the §1915(b) authorities under which this program operates (check each that
applies):


§1915(b)(1) (mandated enrollment to
managed care)



§1915(b)(3) (employ cost savings
to furnish additional services)



§1915(b)(2) (central broker)



§1915(b)(4) (selective
contracting/limit number of
providers)



A program operated under §1932(a) of the Act.
Specify the nature of the State Plan benefit and indicate whether the State Plan Amendment
has been submitted or previously approved:



A program authorized under §1915(i) of the Act.



A program authorized under §1915(j) of the Act.



A program authorized under §1115 of the Act.
Specify the program:

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

State:
Effective Date

Application: 4

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

State:
Effective Date

Application: 5

3. Components of the Waiver Request
The waiver application consists of the following components. Note: Item 3-E must be completed.
A. Waiver Administration and Operation. Appendix A specifies the administrative and operational
structure of this waiver.
B. Participant Access and Eligibility. Appendix B specifies the target group(s) of individuals who are
served in this waiver, the number of participants that the State expects to serve during each year that the
waiver is in effect, applicable Medicaid eligibility and post-eligibility (if applicable) requirements, and
procedures for the evaluation and reevaluation of level of care.
C. Participant Services. Appendix C specifies the home and community-based waiver services that are
furnished through the waiver, including applicable limitations on such services.
D. Participant-Centered Service Planning and Delivery. Appendix D specifies the procedures and
methods that the State uses to develop, implement and monitor the participant-centered service plan (of
care).
E. Participant-Direction of Services. When the State provides for participant direction of services,
Appendix E specifies the participant direction opportunities that are offered in the waiver and the
supports that are available to participants who direct their services. (Select one):



Yes. This waiver provides participant direction opportunities. Appendix E is required.
No. This waiver does not provide participant direction opportunities.
Appendix E is not required.

Participant Rights. Appendix F specifies how the State informs participants of their Medicaid Fair
Hearing rights and other procedures to address participant grievances and complaints.
G. Participant Safeguards. Appendix G describes the safeguards that the State has established to assure
the health and welfare of waiver participants in specified areas.
H. Quality Improvement Strategy. Appendix H contains the Quality Improvement Strategy for this
waiver.
I. Financial Accountability. Appendix I describes the methods by which the State makes payments for
waiver services, ensures the integrity of these payments, and complies with applicable federal
requirements concerning payments and federal financial participation.
J. Cost-Neutrality Demonstration. Appendix J contains the State’s demonstration that the waiver is
cost-neutral.

State:
Effective Date

Application: 6

4. Waiver(s) Requested
A. Comparability. The State requests a waiver of the requirements contained in §1902(a)(10)(B) of the
Act in order to provide the services specified in Appendix C that are not otherwise available under the
approved Medicaid State plan to individuals who: (a) require the level(s) of care specified in Item 1.F
and (b) meet the target group criteria specified in Appendix B.
B. Income and Resources for the Medically Needy. Indicate whether the State requests a waiver of
§1902(a)(10)(C)(i)(III) of the Act in order to use institutional income and resource rules for the
medically needy (select one):


Not Applicable



No
Yes



C. Statewideness. Indicate whether the State requests a waiver of the statewideness requirements in
§1902(a)(1) of the Act (select one):




Yes

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

Geographic Limitation. A waiver of statewideness is requested in order to furnish services
under this waiver only to individuals who reside in the following geographic areas or political
subdivisions of the State.
Specify the areas to which this waiver applies and, as applicable, the phase-in schedule of the
waiver by geographic area:



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

State:
Effective Date

Application: 7

5. Assurances
In accordance with 42 CFR §441.302, the State provides the following assurances to CMS:
A. Health & Welfare: The State assures that necessary safeguards have been taken to protect the health
and welfare of persons receiving services under this waiver. These safeguards include:
1. As specified in Appendix C, adequate standards for all types of providers that provide services under
this waiver;
2. Assurance that the standards of any State licensure or certification requirements specified in
Appendix C are met for services or for individuals furnishing services that are provided under the
waiver. The State assures that these requirements are met on the date that the services are furnished;
and,
3. Assurance that all facilities subject to §1616(e) of the Act where home and community-based waiver
services are provided comply with the applicable State standards for board and care facilities as
specified in Appendix C.
B. Financial Accountability. The State assures financial accountability for funds expended for home and
community-based services and maintains and makes available to the Department of Health and Human
Services (including the Office of the Inspector General), the Comptroller General, or other designees,
appropriate financial records documenting the cost of services provided under the waiver. Methods of
financial accountability are specified in Appendix I.
C. Evaluation of Need: The State assures that it provides for an initial evaluation (and periodic
reevaluations, at least annually) of the need for a level of care specified for this waiver, when there is a
reasonable indication that an individual might need such services in the near future (one month or less)
but for the receipt of home and community-based services under this waiver. The procedures for
evaluation and reevaluation of level of care are specified in Appendix B.
D. Choice of Alternatives: The State assures that when an individual is determined to be likely to require
the level of care specified for this waiver and is in a target group specified in Appendix B, the individual
(or, legal representative, if applicable) is:
1. Informed of any feasible alternatives under the waiver; and,
2. Given the choice of either institutional or home and community-based waiver services.

Appendix B specifies the procedures that the State employs to ensure that individuals are informed of

feasible alternatives under the waiver and given the choice of institutional or home and communitybased waiver services.
E. Average Per Capita Expenditures: The State assures that, for any year that the waiver is in effect, the
average per capita expenditures under the waiver will not exceed 100 percent of the average per capita
expenditures that would have been made under the Medicaid State plan for the level(s) of care specified
for this waiver had the waiver not been granted. Cost-neutrality is demonstrated in Appendix J.
F. Actual Total Expenditures: The State assures that the actual total expenditures for home and
community-based waiver and other Medicaid services and its claim for FFP in expenditures for the
services provided to individuals under the waiver will not, in any year of the waiver period, exceed 100
percent of the amount that would be incurred in the absence of the waiver by the State's Medicaid
program for these individuals in the institutional setting(s) specified for this waiver.
G. Institutionalization Absent Waiver: The State assures that, absent the waiver, individuals served in
the waiver would receive the appropriate type of Medicaid-funded institutional care for the level of care
specified for this waiver.
H. Reporting: The State assures that annually it will provide CMS with information concerning the impact
of the waiver on the type, amount and cost of services provided under the Medicaid State plan and on
the health and welfare of waiver participants. This information will be consistent with a data collection
plan designed by CMS.
State:
Effective Date

Application: 8

Habilitation Services. The State assures that prevocational, educational, or supported employment
services, or a combination of these services, if provided as habilitation services under the waiver are:
(1) not otherwise available to the individual through a local educational agency under the Individuals
with Disabilities Education Improvement Act of 2004 (IDEA) or the Rehabilitation Act of 1973; and,
(2) furnished as part of expanded habilitation services.
J. Services for Individuals with Chronic Mental Illness. The State assures that federal financial
participation (FFP) will not be claimed in expenditures for waiver services including, but not limited to,
day treatment or partial hospitalization, psychosocial rehabilitation services, and clinic services provided
as home and community-based services to individuals with chronic mental illnesses if these individuals,
in the absence of a waiver, would be placed in an IMD and are: (1) age 22 to 64; (2) age 65 and older
and the State has not included the optional Medicaid benefit cited in 42 CFR §440.140; or (3) age 21
and under and the State has not included the optional Medicaid benefit cited
in 42 CFR §440.160.

State:
Effective Date

Application: 9

6. Additional Requirements
Note: Item 6-I must be completed.
A. Service Plan. In accordance with 42 CFR §441.301(b)(1)(i), a participant-centered service plan (of
care) is developed for each participant employing the procedures specified in Appendix D. All waiver
services are furnished pursuant to the service plan. The service plan describes: (a) the waiver services
that are furnished to the participant, their projected frequency and the type of provider that furnishes
each service and (b) the other services (regardless of funding source, including State plan services) and
informal supports that complement waiver services in meeting the needs of the participant. The service
plan is subject to the approval of the Medicaid agency. Federal financial participation (FFP) is not
claimed for waiver services furnished prior to the development of the service plan or for services that
are not included in the service plan.
B. Inpatients. In accordance with 42 CFR §441.301(b)(1)(ii), waiver services are not furnished to
individuals who are in-patients of a hospital, nursing facility or ICF/IID.
C. Room and Board. In accordance with 42 CFR §441.310(a)(2), FFP is not claimed for the cost of room
and board except when: (a) provided as part of respite services in a facility approved by the State that is
not a private residence or (b) claimed as a portion of the rent and food that may be reasonably attributed
to an unrelated caregiver who resides in the same household as the participant, as provided in Appendix
I.
D. Access to Services. The State does not limit or restrict participant access to waiver services except as
provided in Appendix C.
E. Free Choice of Provider. In accordance with 42 CFR §431.151, a participant may select any willing
and qualified provider to furnish waiver services included in the service plan unless the State has
received approval to limit the number of providers under the provisions of §1915(b) or another provision
of the Act.
F. FFP Limitation. In accordance with 42 CFR §433 Subpart D, FFP is not claimed for services when
another third-party (e.g., another third party health insurer or other federal or state program) is legally
liable and responsible for the provision and payment of the service. FFP also may not be claimed for
services that are available without charge, or as free care to the community. Services will not be
considered to be without charge, or free care, when (1) the provider establishes a fee schedule for each
service available and (2) collects insurance information from all those served (Medicaid, and nonMedicaid), and bills other legally liable third party insurers. Alternatively, if a provider certifies that a
particular legally liable third party insurer does not pay for the service(s), the provider may not generate
further bills for that insurer for that annual period.
G. Fair Hearing: The State provides the opportunity to request a Fair Hearing under 42 CFR §431
Subpart E, to individuals: (a) who are not given the choice of home and community-based waiver
services as an alternative to institutional level of care specified for this waiver; (b) who are denied the
service(s) of their choice or the provider(s) of their choice; or (c) whose services are denied, suspended,
reduced or terminated. Appendix F specifies the State’s procedures to provide individuals the
opportunity to request a Fair Hearing, including providing notice of action as required in
42 CFR §431.210.
H. Quality Improvement. The State operates a formal, comprehensive system to ensure that the waiver
meets the assurances and other requirements contained in this application. Through an ongoing process
of discovery, remediation and improvement, the State assures the health and welfare of participants by
monitoring: (a) level of care determinations; (b) individual plans and services delivery; (c) provider
qualifications; (d) participant health and welfare; (e) financial oversight and (f) administrative oversight
of the waiver. The State further assures that all problems identified through its discovery processes are
addressed in an appropriate and timely manner, consistent with the severity and nature of the problem.

State:
Effective Date

Application: 10

During the period that the waiver is in effect, the State will implement the Quality Improvement Strategy
specified throughout the application and in Appendix H.
Public Input. Describe how the State secures public input into the development of the waiver:

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

State:
Effective Date

Application: 11

7. Contact Person(s)
A. The Medicaid agency representative with whom CMS should communicate regarding the waiver is:
Last Name:
First Name:
Title:
Agency:
Address :
Address 2:
City:
State:
Zip:
Phone:
Fax:

Ext:



TTY

E-mail:
B.

If applicable, the State operating agency representative with whom CMS should communicate regarding
the waiver is:
Last Name:
First Name:
Title:
Agency:
Address:
Address 2:
City:
State:
Zip :
Phone:
Fax:

Ext:



TTY

E-mail:

State:
Effective Date

Application: 12

8. Authorizing Signature
This document, together with Appendices A through J, constitutes the State's request for a waiver under
§1915(c) of the Social Security Act. The State assures that all materials referenced in this waiver application
(including standards, licensure and certification requirements) are readily available in print or electronic form
upon request to CMS through the Medicaid agency or, if applicable, from the operating agency specified in
Appendix A. Any proposed changes to the waiver will be submitted by the Medicaid agency to CMS in the
form of waiver amendments.
Upon approval by CMS, the waiver application serves as the State's authority to provide home and communitybased waiver services to the specified target groups. The State attests that it will abide by all provisions of the
approved waiver and will continuously operate the waiver in accordance with the assurances specified in
Section 5 and the additional requirements specified in Section 6 of the request.
Signature:
_________________________________
State Medicaid Director or Designee

Submission
Date:

Note: The Signature and Submission Date fields will be automatically completed when the State
Medicaid Director submits the application.
Last Name:
First Name:
Title:
Agency:
Address:
Address 2:
City:
State:
Zip:
Phone:
Fax:

Ext:



TTY

E-mail:

State:
Effective Date

Application: 13

Attachment #1: Transition Plan
Specify the transition plan for the waiver:

State:
Effective Date

Attachments to Application: 1

Attachment #2: Home and Community-Based Settings Waiver Transition Plan
Specify the state's process to bring this waiver into compliance with federal home and communitybased (HCB) settings requirements at 42 CFR 441.301(c)(4)-(5), and associated CMS guidance.
Consult with CMS for instructions before completing this item. This field describes the status of a
transition process at the point in time of submission. Relevant information in the planning phase
will differ from information required to describe attainment of milestones.
To the extent that the state has submitted a statewide HCB settings transition plan to CMS, the
description in this field may reference that statewide plan. The narrative in this field must include
enough information to demonstrate that this waiver complies with federal HCB settings
requirements, including the compliance and transition requirements at 42 CFR 441.301(c)(6), and
that this submission is consistent with the portions of the statewide HCB settings transition plan that
are germane to this waiver. Quote or summarize germane portions of the statewide HCB settings
transition plan as required.
Note that Appendix C-5 HCB Settings describes settings that do not require transition; the settings
listed there meet federal HCB setting requirements as of the date of submission. Do not duplicate
that information here.
Update this field and Appendix C-5 when submitting a renewal or amendment to this waiver for
other purposes. It is not necessary for the state to amend the waiver solely for the purpose of
updating this field and Appendix C-5. At the end of the state's HCB settings transition process for
this waiver, when all waiver settings meet federal HCB setting requirements, enter "Completed" in
this field, and include in Section C-5 the information on all HCB settings in the waiver.

State:
Effective Date

Attachments to Application: 2

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

State:
Effective Date

Attachments to Application: 3

Appendix A: Waiver Administration and Operation
HCBS Waiver Application Version 3.5

Appendix A: Waiver Administration and Operation
1.

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



The waiver is operated by the State Medicaid agency. Specify the Medicaid agency division/unit
that has line authority for the operation of the waiver program (select one):
 The Medical Assistance Unit (specify the
unit name) (Do not complete
Item A-2)
 Another division/unit within the State Medicaid agency that is separate from the Medical
Assistance
Unit.
Specify
the
division/unit name.
This includes administrations/divisions
under the umbrella agency that has been
identified as the Single State Medicaid
Agency. (Complete item A-2-a)
The waiver is operated by a separate agency of the State that is not a division/unit of the Medicaid
agency. Specify the division/unit name:

In accordance with 42 CFR §431.10, the Medicaid agency exercises administrative discretion in
the administration and supervision of the waiver and issues policies, rules and regulations related
to the waiver. The interagency agreement or memorandum of understanding that sets forth the
authority and arrangements for this policy is available through the Medicaid agency to CMS
upon request. (Complete item A-2-b).
2.

Oversight of Performance.
a. Medicaid Director Oversight of Performance When the Waiver is Operated by another
Division/Unit within the State Medicaid Agency. When the waiver is operated by another
division/administration within the umbrella agency designated as the Single State Medicaid Agency.
Specify (a) the functions performed by that division/administration (i.e., the Developmental Disabilities
Administration within the Single State Medicaid Agency), (b) the document utilized to outline the roles
and responsibilities related to waiver operation, and (c) the methods that are employed by the designated
State Medicaid Director (in some instances, the head of umbrella agency) in the oversight of these
activities.

State:
Effective Date

Appendix A: 1

Appendix A: Waiver Administration and Operation
HCBS Waiver Application Version 3.5

b.
Medicaid Agency Oversight of Operating Agency Performance. When the waiver is not
operated by the Medicaid agency, specify the functions that are expressly delegated through a
memorandum of understanding (MOU) or other written document, and indicate the frequency of review
and update for that document. Specify the methods that the Medicaid agency uses to ensure that the
operating agency performs its assigned waiver operational and administrative functions in accordance
with waiver requirements. Also specify the frequency of Medicaid agency assessment of operating
agency performance:

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

Yes. Contracted entities perform waiver operational and administrative functions on
behalf of the Medicaid agency and/or operating agency (if applicable). Specify the types of
contracted entities and briefly describe the functions that they perform. Complete Items A-5 and
A-6.



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

State:
Effective Date

Appendix A: 2

Appendix A: Waiver Administration and Operation
HCBS Waiver Application Version 3.5

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

Not applicable



Applicable - Local/regional non-state agencies perform waiver operational and
administrative functions. Check each that applies:


Local/Regional non-state public agencies conduct waiver operational and administrative
functions at the local or regional level. There is an interagency agreement or memorandum
of understanding between the Medicaid agency and/or the operating agency (when authorized
by the Medicaid agency) and each local/regional non-state agency that sets forth the
responsibilities and performance requirements of the local/regional agency. The interagency
agreement or memorandum of understanding is available through the Medicaid agency or the
operating agency (if applicable). Specify the nature of these agencies and complete items A-5
and A-6:



Local/Regional non-governmental non-state entities conduct waiver operational and
administrative functions at the local or regional level. There is a contract between the
Medicaid agency and/or the operating agency (when authorized by the Medicaid agency) and
each local/regional non-state entity that sets forth the responsibilities and performance
requirements of the local/regional entity. The contract(s) under which private entities conduct
waiver operational functions are available to CMS upon request through the Medicaid agency
or the operating agency (if applicable). Specify the nature of these entities and complete items
A-5 and A-6:

5. Responsibility for Assessment of Performance of Contracted and/or Local/Regional Non-State
Entities. Specify the state agency or agencies responsible for assessing the performance of contracted
and/or local/regional non-state entities in conducting waiver operational and administrative functions:

6. Assessment Methods and Frequency. Describe the methods that are used to assess the performance of
contracted and/or local/regional non-state entities to ensure that they perform assigned waiver operational
and administrative functions in accordance with waiver requirements. Also specify how frequently the
performance of contracted and/or local/regional non-state entities is assessed:

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

Appendix A: 3

Appendix A: Waiver Administration and Operation
HCBS Waiver Application Version 3.5

In accordance with 42 CFR §431.10, when the Medicaid agency does not directly conduct a function, it
supervises the performance of the function and establishes and/or approves policies that affect the
function. All functions not performed directly by the Medicaid agency must be delegated in writing and
monitored by the Medicaid Agency. Note: More than one box may be checked per item. Ensure that
Medicaid is checked when the Single State Medicaid Agency (1) conducts the function directly; (2)
supervises the delegated function; and/or (3) establishes and/or approves policies related to the function.
Medicaid
Agency

Other State
Operating
Agency

Contracted
Entity

Local
Non-State
Entity

Participant waiver enrollment



Waiver enrollment managed against approved
limits



Waiver expenditures managed against approved
levels



Level of care evaluation



Review of Participant service plans



Prior authorization of waiver services



Utilization management



Qualified provider enrollment



Execution of Medicaid provider agreements



Establishment of a statewide rate methodology



Rules, policies, procedures and information
development governing the waiver program



Quality assurance and quality improvement
activities



Function

State:
Effective Date

Appendix A: 4

Appendix A: Waiver Administration and Operation
HCBS Waiver Application Version 3.5

Quality Improvement: Administrative Authority of the Single State Medicaid
Agency
As a distinct component of the State’s quality improvement strategy, provide information in
the following fields to detail the State’s methods for discovery and remediation.
a.

Methods for Discovery: Administrative Authority
The Medicaid Agency retains ultimate administrative authority and responsibility for the
operation of the waiver program by exercising oversight of the performance of waiver
functions by other state and local/regional non-state agencies (if appropriate) and
contracted entities..

Performance Measures
For each performance measure the State will use to assess compliance with the statutory
assurance complete the following. Performance measures for administrative authority
should not duplicate measures found in other appendices of the waiver application. As
necessary and applicable, performance measures should focus on:
• Uniformity of development/execution of provider agreements throughout all
geographic areas covered by the waiver
• Equitable distribution of waiver openings in all geographic areas covered by the
waiver
• Compliance with HCB settings requirements and other new regulatory
components (for waiver actions submitted on or after March 17, 2014).
Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable
the State to analyze and assess progress toward the performance measure. In this section
provide information on the method by which each source of data is analyzed
statistically/deductively or inductively, how themes are identified or conclusions drawn, and
how recommendations are formulated, where appropriate.
Performance
Measure:
Data Source (Select one) (Several options are listed in the on-line application):
If ‘Other’ is selected, specify:
Responsible Party for
data
collection/generation
(check each that
applies)

State:
Effective Date

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

Appendix A: 5

Appendix A: Waiver Administration and Operation
HCBS Waiver Application Version 3.5

 State Medicaid Agency  Weekly
 Operating Agency
 Monthly
 Sub-State Entity

 Quarterly

 Other

 Annually

 100% Review
 Less than 100%
Review
 Representative
Sample; Confidence
Interval =

Specify:

 Continuously and

 Stratified:

Ongoing

Describe Group:

 Other
Specify:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

(check each that
applies
 Weekly
 Monthly
 Quarterly
 Annually

Specify:

 Continuously and
Ongoing
 Other
Specify:

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

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

Methods for Remediation/Fixing Individual Problems

State:
Effective Date

Appendix A: 6

Appendix A: Waiver Administration and Operation
HCBS Waiver Application Version 3.5

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

Remediation Data Aggregation

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

Responsible Party (check

each that applies)

 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

Frequency of data
aggregation and
analysis:

(check each that
applies)
 Weekly
 Monthly
 Quarterly
 Annually

Specify:

 Continuously and
Ongoing
 Other
Specify:

Timelines

When the State does not have all elements of the Quality Improvement Strategy in place,

provide timelines to design methods for discovery and remediation related to the assurance

of Administrative Authority that are currently non-operational.



Yes

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

State:
Effective Date

Appendix A: 7

Appendix B: Participant Access and Eligibility
HCBS Waiver Application Version 3.5

Appendix B: Participant Access and Eligibility
Appendix B-1: Specification of the Waiver Target Group(s)
a. Target Group(s). Under the waiver of Section 1902(a)(10)(B) of the Act, the State limits waiver services
to a group or subgroups of individuals. In accordance with 42 CFR §441.301(b)(6), select one waiver
target group, check each subgroup in the selected target group that may receive services under the waiver,
and specify the minimum and maximum (if any) age of individuals served in each subgroup:
SELECT

ONE

WAIVER

TARGET

GROUP



TARGET GROUP/SUBGROUP

Aged or Disabled, or Both - General
Aged (age 65 and older)

Disabled (Physical)

Disabled (Other)




Aged or Disabled, or Both - Specific Recognized Subgroups







MINIMUM AGE

MAXIMUM AGE
MAXIMUM AGE
LIMIT: THROUGH NO MAXIMUM
AGE –
AGE LIMIT

Brain Injury
HIV/AIDS
Medically Fragile
Technology Dependent






Intellectual Disability or Developmental Disability, or Both
 Autism
 Developmental Disability
 Mental Retardation
Mental Illness (check each that applies)
 Mental Illness
Serious Emotional Disturbance







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

Transition of Individuals Affected by Maximum Age Limitation. When there is a maximum age limit
that applies to individuals who may be served in the waiver, describe the transition planning procedures
that are undertaken on behalf of participants affected by the age limit (select one):
 Not applicable.There is no maximum age limit
 The following transition planning procedures are employed for participants who will reach the
waiver’s maximum age limit. Specify:

State:
Effective Date

Appendix B-1: 1

Appendix B-2: Individual Cost Limit
a. Individual Cost Limit. The following individual cost limit applies when determining whether to deny
home and community-based services or entrance to the waiver to an otherwise eligible individual (select
one). Please note that a State may have only ONE individual cost limit for the purposes of determining
eligibility for the waiver:


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



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

A level higher than 100% of the institutional average
Specify the percentage:

 Other (specify):



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



Cost Limit Lower Than Institutional Costs. The State refuses entrance to the waiver to any
otherwise qualified individual when the State reasonably expects that the cost of home and
community-based services furnished to that individual would exceed the following amount
specified by the State that is less than the cost of a level of care specified for the waiver. Specify
the basis of the limit, including evidence that the limit is sufficient to assure the health and welfare
of waiver participants. Complete Items B-2-b and B-2-c.

The cost limit specified by the State is (select one):
 The following dollar amount:

Specify dollar amount:
The dollar amount (select one):
 Is adjusted each year that the waiver is in effect by applying the following
formula:

Specify the formula:

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

State:
Effective Date

Appendix B-2: 1

 The following percentage that is less than 100% of the institutional
average:
 Other:
Specify:

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

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

The participant is referred to another waiver that can accommodate the individual’s needs.



Additional services in excess of the individual cost limit may be authorized.
Specify the procedures for authorizing additional services, including the amount that may be
authorized:



Other safeguard(s)
(Specify):

State:
Effective Date

Appendix B-2: 2

Appendix B-3: Number of Individuals Served
a. Unduplicated Number of Participants. The following table specifies the maximum number of
unduplicated participants who are served in each year that the waiver is in effect. The State will submit a
waiver amendment to CMS to modify the number of participants specified for any year(s), including when
a modification is necessary due to legislative appropriation or another reason. The number of
unduplicated participants specified in this table is basis for the cost-neutrality calculations in
Appendix J:
Table: B-3-a
Waiver Year

Unduplicated
Number
of Participants

Year 1
Year 2
Year 3
Year 4 (only appears if applicable
based on Item 1-C)
Year 5 (only appears if applicable
based on Item 1-C)
b. Limitation on the Number of Participants Served at Any Point in Time. Consistent with the
unduplicated number of participants specified in Item B-3-a, the State may limit to a lesser number the
number of participants who will be served at any point in time during a waiver year. Indicate whether the
State limits the number of participants in this way: (select one):


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



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

The limit that applies to each year of the waiver period is specified in the following table:
Table B-3-b
Waiver Year

Maximum Number of
Participants Served At Any
Point During the Year

Year 1
Year 2
Year 3
Year 4 (only appears if applicable based on Item 1-C)
Year 5 (only appears if applicable based on Item 1-C)

State:
Effective Date

Appendix B-3: 1

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

Not applicable. The state does not reserve capacity.



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

Purpose(s) the State reserves capacity for:
Table B-3-c

Waiver Year

Purpose (provide a title or
short description to use for
lookup):

Purpose (describe):

Describe how the amount
of reserved capacity was
determined:

Describe how the amount of
reserved capacity was
determined:

Capacity Reserved

Year 1
Year 2
Year 3
Year 4 (only if applicable
based on Item 1-C)
Year 5 (only if applicable
based on Item 1-C)
d.

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

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



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

State:
Effective Date

Appendix B-3: 2

Allocation of Waiver Capacity.
Select one:



Waiver capacity is allocated/managed on a statewide basis.



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

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

State:
Effective Date

Appendix B-3: 3

B-3: Number of Individuals Served - Attachment #1
Waiver Phase-In/Phase Out Schedule

Based on Waiver Proposed Effective Date:
a.

The waiver is being (select one):


Phased-in



Phased-out

Phase-In/Phase-Out Time Schedule. Complete the following table:
Beginning (base) number of Participants:

Phase-In or Phase-Out Schedule
Waiver Year:
Month

Base Number of
Participants

Change in Number
of Participants

Participant Limit

Waiver Years Subject to Phase-In/Phase-Out Schedule (check each that applies):
Year One

Year Two

Year Three

Year Four

Your Five



State:
Effective Date

Appendix B-3: 4

Phase-In/Phase-Out Time Period. Complete the following table:
Month

Waiver Year

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

State:
Effective Date

Appendix B-3: 5

Appendix B-4: Medicaid Eligibility Groups Served in the Waiver
a.

1. State Classification. The State is a (select one):




§1634 State
SSI Criteria State
209(b) State

2. Miller Trust State.

Indicate whether the State is a Miller Trust State (select one).




No
Yes

b. Medicaid Eligibility Groups Served in the Waiver. Individuals who receive services under this waiver
are eligible under the following eligibility groups contained in the State plan. The State applies all
applicable federal financial participation limits under the plan. Check all that apply:
Eligibility Groups Served in the Waiver (excluding the special home and community-based waiver
group under 42 CFR §435.217)


Low income families with children as provided in §1931 of the Act



SSI recipients



Aged, blind or disabled in 209(b) states who are eligible under 42 CFR §435.121



Optional State supplement recipients



Optional categorically needy aged and/or disabled individuals who have income at: (select one)



100% of the Federal poverty level (FPL)
% of FPL, which is lower than 100% of FPL

Specify percentage:


Working individuals with disabilities who buy into Medicaid (BBA working disabled group as
provided in §1902(a)(10)(A)(ii)(XIII)) of the Act)



Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group
as provided in §1902(a)(10)(A)(ii)(XV) of the Act)



Working individuals with disabilities who buy into Medicaid (TWWIIA Medical Improvement
Coverage Group as provided in §1902(a)(10)(A)(ii)(XVI) of the Act)



Disabled individuals age 18 or younger who would require an institutional level of care (TEFRA
134 eligibility group as provided in §1902(e)(3) of the Act)



Medically needy in 209(b) States (42 CFR §435.330)



Medically needy in 1634 States and SSI Criteria States (42 CFR §435.320, §435.322 and
§435.324)



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

State:
Effective Date

Appendix B-4: 1

Special home and community-based waiver group under 42 CFR §435.217) Note: When the special
home and community-based waiver group under 42 CFR §435.217 is included, Appendix B-5 must be
completed


No. The State does not furnish waiver services to individuals in the special home and communitybased waiver group under 42 CFR §435.217. Appendix B-5 is not submitted.



Yes. The State furnishes waiver services to individuals in the special home and community-based
waiver group under 42 CFR §435.217. Select one and complete Appendix B-5.


All individuals in the special home and community-based waiver group under
42 CFR §435.217



Only the following groups of individuals in the special home and community-based waiver
group under 42 CFR §435.217 (check each that applies):

A special income level equal to (select one):
 300% of the SSI Federal Benefit Rate (FBR)

% A percentage of FBR, which is lower than 300% (42 CFR

§435.236)



Specify percentage:
A dollar amount which is lower than 300%
Specify percentage:








State:
Effective Date

Aged, blind and disabled individuals who meet requirements that are more restrictive
than the SSI program (42 CFR §435.121)
Medically needy without spend down in States which also provide Medicaid to
recipients of SSI (42 CFR §435.320, §435.322 and §435.324)
Medically needy without spend down in 209(b) States (42 CFR §435.330)
Aged and disabled individuals who have income at: (select one)
 100% of FPL

% of FPL, which is lower than 100%
Other specified groups (include only the statutory/regulatory reference to reflect the
additional groups in the State plan that may receive services under this waiver) specify:

Appendix B-4: 2

Appendix B-5: Post-Eligibility Treatment of Income
In accordance with 42 CFR §441.303(e), Appendix B-5 must be completed when the State furnishes waiver
services to individuals in the special home and community-based waiver group under 42 CFR §435.217, as
indicated in Appendix B-4. Post-eligibility applies only to the 42 CFR §435.217 group.
a. Use of Spousal Impoverishment Rules. Indicate whether spousal impoverishment rules are used to
determine eligibility for the special home and community-based waiver group under 42 CFR §435.217.
Note: For the five-year period beginning January 1, 2014, the following instructions are mandatory. The
following box should be checked for all waivers that furnish waiver services to the 42 CFR §435.217
group effective at any point during this time period.


Spousal impoverishment rules under §1924 of the Act are used to determine the eligibility of
individuals with a community spouse for the special home and community-based waiver
group. In the case of a participant with a community spouse, the State uses spousal posteligibility rules under §1924 of the Act. Complete Items B-5-e (if the selection for B-4-a-i is SSI
State or §1634) or B-5-f (if the selection for B-4-a-i is 209b State) and Item B-5-g unless the state
indicates that it also uses spousal post-eligibility rules for the time periods before January 1,
2014 or after December 31, 2018.

Note: The following selections apply for the time periods before January 1, 2014 or after
December 31, 2018 (select one).




Use spousal post-eligibility rules under §1924 of the Act. Complete ItemsB-5-b-2 (SSI
State and §1634) or B-5-c-2 (209b State) and Item B-5-d.



Use regular post-eligibility rules under 42 CFR §435.726 (SSI State and §1634) (Complete
Item B-5-b-1) or under §435.735 (209b State) (Complete Item B-5-c-1). Do not complete
Item B-5-d.

Spousal impoverishment rules under §1924 of the Act are not used to determine eligibility of
individuals with a community spouse for the special home and community-based waiver group.
The State uses regular post-eligibility rules for individuals with a community spouse. Complete
Item B-5-c-1 (SSI State and §1634) or Item B-5-d-1 (209b State). Do not complete Item B-5-d.

NOTE: Items B-5-b-1 and B-5-c-1 are for use by states that do not use spousal eligibility rules or use
spousal impoverishment eligibility rules but elect to use regular post-eligibility rules. However, for the
five-year period beginning on January 1, 2014, post-eligibility treatment-of-income rules may not be
determined in accordance with B-5-b-1 and B-5-c-1, because use of spousal eligibility and post-eligibility
rules are mandatory during this time period.

State:
Effective Date

Appendix B-5: 1

Note: The following selections apply for the time periods before January 1, 2014 or after
December 31, 2018.
b-1. Regular Post-Eligibility Treatment of Income: SSI State. The State uses the post-eligibility rules at 42
CFR §435.726. Payment for home and community-based waiver services is reduced by the amount
remaining after deducting the following allowances and expenses from the waiver participant’s income:
i. Allowance for the needs of the waiver participant (select one):
 The following standard included under the State plan
(Select one):

SSI standard

Optional State supplement standard

Medically needy income standard

The special income level for institutionalized persons
(select one):
 300% of the SSI Federal Benefit Rate (FBR)
A percentage of the FBR, which is less than 300%
%

Specify the percentage:
A dollar amount which is less than 300%.
 $
Specify dollar amount:

% A percentage of the Federal poverty level
Specify percentage:

Other standard included under the State Plan
Specify:

If this amount changes, this item will be revised.
 The following dollar amount
$
Specify dollar amount:
 The following formula is used to determine the needs allowance:
Specify:

 Other
Specify:
ii. Allowance for the spouse only (select one):
 Not Applicable
Specify the amount of the allowance (select one):
 SSI standard
 Optional State supplement standard
 Medically needy income standard
 The following dollar amount: $
If this amount changes, this item will be revised.
Specify dollar amount:
 The amount is determined using the following formula:
State:
Effective Date

Appendix B-5: 2

Specify:

iii. Allowance for the family (select one):
 Not Applicable (see instructions)
 AFDC need standard
 Medically needy income standard




$
The following dollar amount:
Specify dollar amount:
The amount specified cannot exceed the higher
of the need standard for a family of the same size used to determine eligibility under the State’s
approved AFDC plan or the medically needy income standard established under
42 CFR §435.811 for a family of the same size. If this amount changes, this item will be revised.
The amount is determined using the following formula:
Specify:

Other
Specify:

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

Not applicable (see instructions) Note: If the State protects the maximum amount for the waiver
participant, not applicable must be selected.



The State does not establish reasonable limits.



The State establishes the following reasonable limits
Specify:

State:
Effective Date

Appendix B-5: 3

Note: The following selections apply for the time periods before January 1, 2014 or after
December 31, 2018.
c-1. Regular Post-Eligibility Treatment of Income: 209(B) State. The State uses more restrictive eligibility
requirements than SSI and uses the post-eligibility rules at 42 CFR §435.735. Payment for home and
community-based waiver services is reduced by the amount remaining after deducting the following
amounts and expenses from the waiver participant’s income:
i. Allowance for the needs of the waiver participant (select one):
 The following standard included under the State plan (select one)

The following standard under 42 CFR §435.121
Specify:








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

The following dollar amount:

Specify dollar amount: If this amount changes, this
item will be revised.
The following formula is used to determine the needs allowance
Specify:

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



State:
Effective Date

Optional State supplement standard

Appendix B-5: 4





Medically needy income standard
The following dollar amount: $
If this amount changes, this item will be revised.
Specify dollar amount:
The amount is determined using the following formula:
Specify:

iii. Allowance for the family (select one)




Not applicable (see instructions)
AFDC need standard
Medically needy income standard



The following dollar amount: $
Specify dollar amount:
The amount specified cannot exceed the higher
of the need standard for a family of the same size used to determine eligibility under the State’s
approved AFDC plan or the medically needy income standard established under
42 CFR §435.811 for a family of the same size. If this amount changes, this item will be revised.
The amount is determined using the following formula:
Specify:



Other (specify):

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

Not applicable (see instructions) Note: If the State protects the maximum amount for the waiver
participant, not applicable must be checked.



The State does not establish reasonable limits.



The State establishes the following reasonable limits (specify):

NOTE: Items B-5-b-2 and B-5-c-2 are for use by states that use spousal impoverishment eligibility rules
and elect to apply the spousal post eligibility rules.

State:
Effective Date

Appendix B-5: 5

Note: The following selections apply for the time periods before January 1, 2014 or after
December 31, 2018.
b-2. Regular Post-Eligibility Treatment of Income: SSI State. The State uses the post-eligibility rules at 42
CFR §435.726 for individuals who do not have a spouse or have a spouse who is not a community spouse
as specified in §1924 of the Act. Payment for home and community-based waiver services is reduced by
the amount remaining after deducting the following allowances and expenses from the waiver
participant’s income:
i. Allowance for the needs of the waiver participant (select one):
 The following standard included under the State plan
(Select one):

SSI standard

Optional State supplement standard

Medically needy income standard

The special income level for institutionalized persons
(select one):
 300% of the SSI Federal Benefit Rate (FBR)
A percentage of the FBR, which is less than 300%
%

Specify the percentage:
A dollar amount which is less than 300%.
 $
Specify dollar amount:

% A percentage of the Federal poverty level
Specify percentage:

Other standard included under the State Plan
Specify:

If this amount changes, this item will be revised.
 The following dollar amount
$
Specify dollar amount:
 The following formula is used to determine the needs allowance:
Specify:

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

Specify the amount of the allowance (select one):
State:
Effective Date

Appendix B-5: 6







SSI standard
Optional State supplement standard
Medically needy income standard
$
If this amount changes, this item will be revised.
The following dollar amount:
Specify dollar amount:
The amount is determined using the following formula:
Specify:

iii. Allowance for the family (select one):
 Not Applicable (see instructions)
 AFDC need standard
 Medically needy income standard




Other
Specify:

Not applicable (see instructions) Note: If the State protects the maximum amount for the waiver
participant, not applicable must be selected.



The State does not establish reasonable limits.



The State establishes the following reasonable limits
Specify:

State:
Effective Date

Appendix B-5: 7

Note: The following selections apply for the time periods before January 1, 2014 or after
December 31, 2018.
c-2. Regular Post-Eligibility Treatment of Income: 209(B) State. The State uses more restrictive eligibility
requirements than SSI and uses the post-eligibility rules at 42 CFR §435.735 for individuals who do not
have a spouse or have a spouse who is not a community spouse as specified in §1924 of the Act. Payment
for home and community-based waiver services is reduced by the amount remaining after deducting the
following amounts and expenses from the waiver participant’s income:
i. Allowance for the needs of the waiver participant (select one):
 The following standard included under the State plan
(Select one):

The following standard under 42 CFR §435.121:
Specify:








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

If this amount changes, this item will be revised.
 The following dollar amount
$
Specify dollar amount:
 The following formula is used to determine the needs allowance:
Specify:

Appendix B-5: 8

Specify:

Specify the amount of the allowance (select one):


The following standard under 42 CFR §435.121:
Specify:





Optional State supplement standard
Medically needy income standard
$
If this amount changes, this item will be revised.
The following dollar amount:
Specify dollar amount:
The amount is determined using the following formula:
Specify:



iii. Allowance for the family (select one):
 Not Applicable (see instructions)
 AFDC need standard
 Medically needy income standard




Other
Specify:

State:
Effective Date

Not applicable (see instructions) Note: If the State protects the maximum amount for the waiver
participant, not applicable must be selected.

Appendix B-5: 9



The State does not establish reasonable limits.



The State establishes the following reasonable limits
Specify:

State:
Effective Date

Appendix B-5: 10

Note: The following selections apply for the time periods before January 1, 2014 or after
December 31, 2018.
d.

Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules
The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to
determine the contribution of a participant with a community spouse toward the cost of home and communitybased care if it determines the individual's eligibility under §1924 of the Act. There is deducted from the
participant’s monthly income a personal needs allowance (as specified below), a community spouse's
allowance and a family allowance as specified in the State Medicaid Plan. The State must also protect amounts
for incurred expenses for medical or remedial care (as specified below).
i. Allowance for the personal needs of the waiver participant
(select one):








SSI Standard
Optional State supplement standard
Medically needy income standard
The special income level for institutionalized persons
% Specify percentage:
$
If this amount changes, this item will be revised
The following dollar amount:
The following formula is used to determine the needs allowance:
Specify formula:

 Other
Specify:

ii.

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

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

Not applicable (see instructions) Note: If the State protects the maximum amount for the waiver
participant, not applicable must be selected.



The State does not establish reasonable limits.

State:
Effective Date

Appendix B-5: 11



The State uses the same reasonable limits as are used for regular (non-spousal) posteligibility.

NOTE: Items B-5-e, B-5-f and B-5-g only apply for the five-year period beginning January 1, 2014. If
the waiver is effective during the five-year period beginning January 1, 2014, and if the state indicated
in B-5-a that it uses spousal post-eligibility rules under §1924 of the Act before January 1, 2014 or after
December 31, 2018, then Items B-5-e, B-5-f and/or B-5-g are not necessary. The state’s entries in B-5
b-2, B-5-c-2, and B-5-d, respectively, will apply.

State:
Effective Date

Appendix B-5: 12

Note: The following selections apply for the five-year period beginning January 1, 2014.
e.

Regular Post-Eligibility Treatment of Income: SSI State and §1634 state – 2014 through 2018. The
State uses the post-eligibility rules at 42 CFR §435.726 for individuals who do not have a spouse or have
a spouse who is not a community spouse as specified in §1924 of the Act. Payment for home and
community-based waiver services is reduced by the amount remaining after deducting the following
allowances and expenses from the waiver participant’s income:
i. Allowance for the needs of the waiver participant (select one):
 The following standard included under the State plan
(Select one):

SSI standard

Optional State supplement standard

Medically needy income standard

The special income level for institutionalized persons
(select one):
 300% of the SSI Federal Benefit Rate (FBR)
A percentage of the FBR, which is less than 300%
%

Specify the percentage:
A dollar amount which is less than 300%.
 $
Specify dollar amount:

% A percentage of the Federal poverty level
Specify percentage:

Other standard included under the State Plan
Specify:

If this amount changes, this item will be revised.
 The following dollar amount
$
Specify dollar amount:
 The following formula is used to determine the needs allowance:
Specify:

Specify the amount of the allowance (select one):
 SSI standard
State:
Effective Date

Appendix B-5: 13






iii. Allowance for the family (select one):
 Not Applicable (see instructions)
 AFDC need standard
 Medically needy income standard




Other
Specify:

Not applicable (see instructions) Note: If the State protects the maximum amount for the waiver
participant, not applicable must be selected.



The State does not establish reasonable limits.



The State establishes the following reasonable limits
Specify:

State:
Effective Date

Appendix B-5: 14

Note: The following selections apply for the five-year period beginning January 1, 2014.
f.

Regular Post-Eligibility: 209(b) State – 2014 through 2018. The State uses more restrictive eligibility
requirements than SSI and uses the post-eligibility rules at 42 CFR §435.735 for individuals who do not
have a spouse or have a spouse who is not a community spouse as specified in §1924 of the Act. Payment
for home and community-based waiver services is reduced by the amount remaining after deducting the
following amounts and expenses from the waiver participant’s income:
i. Allowance for the needs of the waiver participant (select one):
 The following standard included under the State plan
(Select one):

The following standard under 42 CFR §435.121:
Specify:








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

If this amount changes, this item will be revised.
 The following dollar amount
$
Specify dollar amount:
 The following formula is used to determine the needs allowance:
Specify:

Appendix B-5: 15

Specify the amount of the allowance (select one):


The following standard under 42 CFR §435.121:
Specify:







iii. Allowance for the family (select one):
 Not Applicable (see instructions)
 AFDC need standard
 Medically needy income standard




Other
Specify:

Not applicable (see instructions) Note: If the State protects the maximum amount for the waiver
participant, not applicable must be selected.



The State does not establish reasonable limits.

State:
Effective Date

Appendix B-5: 16



State:
Effective Date

The State establishes the following reasonable limits
Specify:

Appendix B-5: 17

Note: The following selections apply for the five-year period beginning January 1, 2014.
g.

Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules – 2014 through 2018
The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to
determine the contribution of a participant with a community spouse toward the cost of home and
community-based care. There is deducted from the participant’s monthly income a personal needs
allowance (as specified below), a community spouse's allowance and a family allowance as specified in
the State Medicaid Plan. The State must also protect amounts for incurred expenses for medical or
remedial care (as specified below).
i. Allowance for the personal needs of the waiver participant
(select one):








 Other
Specify:

ii.

Not applicable (see instructions) Note: If the State protects the maximum amount for the waiver
participant, not applicable must be selected.



The State does not establish reasonable limits.

State:
Effective Date

Appendix B-5: 18



The State uses the same reasonable limits as are used for regular (non-spousal) posteligibility.

State:
Effective Date

Appendix B-5: 19

Appendix B-6: Evaluation / Reevaluation of Level of Care
As specified in 42 CFR §441.302(c), the State provides for an evaluation (and periodic reevaluations) of the
need for the level(s) of care specified for this waiver, when there is a reasonable indication that an individual
may need such services in the near future (one month or less), but for the availability of home and communitybased waiver services.
a. Reasonable Indication of Need for Services. In order for an individual to be determined to need waiver
services, an individual must require: (a) the provision of at least one waiver service, as documented in the
service plan, and (b) the provision of waiver services at least monthly or, if the need for services is less
than monthly, the participant requires regular monthly monitoring which must be documented in the
service plan. Specify the State’s policies concerning the reasonable indication of the need for waiver
services:
i.

Minimum number of services.
The minimum number of waiver services (one or more) that an individual must require in order
to be determined to need waiver services is:

ii.

Frequency of services. The State requires (select one):
 The provision of waiver services at least monthly


Monthly monitoring of the individual when services are furnished on a less than monthly
basis
If the State also requires a minimum frequency for the provision of waiver services other than
monthly (e.g., quarterly), specify the frequency:

Responsibility for Performing Evaluations and Reevaluations.
reevaluations are performed (select one):


Directly by the Medicaid agency



By the operating agency specified in Appendix A



By an entity under contract with the Medicaid agency.
Specify the entity:



Other
Specify:

Level of care evaluations and

Qualifications of Individuals Performing Initial Evaluation: Per 42 CFR §441.303(c)(1), specify the
educational/professional qualifications of individuals who perform the initial evaluation of level of care
for waiver applicants:

State:
Effective Date

Appendix B-6: 1

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

Level of Care Instrument(s). Per 42 CFR §441.303(c)(2), indicate whether the instrument/tool used to
evaluate level of care for the waiver differs from the instrument/tool used to evaluate institutional level of
care (select one):



The same instrument is used in determining the level of care for the waiver and for
institutional care under the State Plan.
A different instrument is used to determine the level of care for the waiver than for
institutional care under the State plan.
Describe how and why this instrument differs from the form used to evaluate institutional level
of care and explain how the outcome of the determination is reliable, valid, and fully comparable.

Process for Level of Care Evaluation/Reevaluation. Per 42 CFR §441.303(c)(1), describe the process
for evaluating waiver applicants for their need for the level of care under the waiver. If the reevaluation
process differs from the evaluation process, describe the differences:

g. Reevaluation Schedule. Per 42 CFR §441.303(c)(4), reevaluations of the level of care required by a
participant are conducted no less frequently than annually according to the following schedule
(select one):



Every three months



Every six months



Every twelve months



Other schedule
Specify the other schedule:

Qualifications of Individuals Who Perform Reevaluations. Specify the qualifications of individuals
who perform reevaluations (select one):
 The qualifications of individuals who perform reevaluations are the same as individuals who
perform initial evaluations.
 The qualifications are different.
Specify the qualifications:

State:
Effective Date

Appendix B-6: 2

Procedures to Ensure Timely Reevaluations. Per 42 CFR §441.303(c)(4), specify the procedures that
the State employs to ensure timely reevaluations of level of care (specify):

Maintenance of Evaluation/Reevaluation Records. Per 42 CFR §441.303(c)(3), the State assures that
written and/or electronically retrievable documentation of all evaluations and reevaluations are
maintained for a minimum period of 3 years as required in 45 CFR §92.42. Specify the location(s) where
records of evaluations and reevaluations of level of care are maintained:

Quality Improvement: Level of Care
As a distinct component of the State’s quality improvement strategy, provide information in
the following fields to detail the State’s methods for discovery and remediation.
a.

Methods for Discovery: Level of Care Assurance/Sub-assurances
The state demonstrates that it implements the processes and instrument(s) specified in its
approved waiver for evaluating/reevaluating an applicant’s/waiver participant’s level of
care consistent with level of care provided in a hospital, NF or ICF/IID.

Sub-assurances:
a. Sub-assurance: An evaluation for LOC is provided to all applicants for whom there is
reasonable indication that services may be needed in the future.
i. Performance Measures
For each performance measure the State will use to assess compliance with the statutory
assurance complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable
the State to analyze and assess progress toward the performance measure. In this section
provide information on the method by which each source of data is analyzed
statistically/deductively or inductively, how themes are identified or conclusions drawn, and
how recommendations are formulated, where appropriate.

Performance
Measure:
State:
Effective Date

Appendix B-6: 3

Data Source (Select one) (Several options are listed in the on-line application):
If ‘Other’ is selected, specify:
Responsible Party for
data
collection/generation
(check each that
applies)

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

 State Medicaid Agency  Weekly
 Operating Agency
 Monthly
 Sub-State Entity

 Quarterly

 Other

 Annually

 100% Review
 Less than 100%
Review
 Representative
Sample; Confidence
Interval =

Specify:

 Continuously and

 Stratified:

Ongoing
 Other
Specify:

Describe Group:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

(check each that
applies
 Weekly
 Monthly
 Quarterly
 Annually

Specify:

 Continuously and
Ongoing
 Other
Specify:

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

Sub-assurance: The levels of care of enrolled participants are reevaluated at least
annually or as specified in the approved waiver.

State:
Effective Date

Appendix B-6: 4

i. Performance Measures
For each performance measure the State will use to assess compliance with the statutory
assurance complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable
the State to analyze and assess progress toward the performance measure. In this section
provide information on the method by which each source of data is analyzed
statistically/deductively or inductively, how themes are identified or conclusions drawn, and
how recommendations are formulated, where appropriate.
Performance
Measure:
Data Source (Select one) (Several options are listed in the on-line application):
If ‘Other’ is selected, specify:
Responsible Party for
data
collection/generation
(check each that
applies)

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

 State Medicaid Agency  Weekly
 Operating Agency
 Monthly
 Sub-State Entity

 Quarterly

 Other

 Annually

 100% Review
 Less than 100%
Review
 Representative
Sample; Confidence
Interval =

Specify:

 Continuously and

 Stratified:

Ongoing
 Other
Specify:

Describe Group:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies
 State Medicaid Agency
 Operating Agency

(check each that
applies
 Weekly
 Monthly

State:
Effective Date

Appendix B-6: 5

 Sub-State Entity
 Other

 Quarterly
 Annually

Specify:

 Continuously and
Ongoing
 Other
Specify:

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

Sub-assurance: The processes and instruments described in the approved waiver are
applied appropriately and according to the approved description to determine the initial
participant level of care.
i. Performance Measures
For each performance measure the State will use to assess compliance with the statutory
assurance complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable
the State to analyze and assess progress toward the performance measure. In this section
provide information on the method by which each source of data is analyzed
statistically/deductively or inductively, how themes are identified or conclusions drawn, and
how recommendations are formulated, where appropriate.
Performance
Measure:
Data Source (Select one) (Several options are listed in the on-line application):
If ‘Other’ is selected, specify:
Responsible Party for
data
collection/generation
(check each that
applies)

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

 State Medicaid Agency  Weekly
 Operating Agency
 Monthly
 Sub-State Entity

State:
Effective Date

 Quarterly

 100% Review
 Less than 100%
Review
 Representative
Sample; Confidence
Interval =

Appendix B-6: 6

 Other

 Annually

Specify:

 Continuously and

 Stratified:

Ongoing
 Other
Specify:

Describe Group:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

(check each that
applies
 Weekly
 Monthly
 Quarterly
 Annually

Specify:

 Continuously and
Ongoing
 Other
Specify:

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

Methods for Remediation/Fixing Individual Problems

Appendix B-6: 7

Remediation Data Aggregation

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

Responsible Party (check

each that applies)

 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other: Specify:

Frequency of data
aggregation and
analysis:

(check each that
applies)
 Weekly
 Monthly
 Quarterly
 Annually
 Continuously and
Ongoing
 Other: Specify:

Timelines

When the State does not have all elements of the Quality Improvement Strategy in place,

provide timelines to design methods for discovery and remediation related to the assurance

of Level of Care that are currently non-operational.



Yes

Please provide a detailed strategy for assuring Level of Care, the specific timeline for
implementing identified strategies, and the parties responsible for its operation.

State:
Effective Date

Appendix B-6: 8

Appendix B-7: Freedom of Choice
Freedom of Choice. As provided in 42 CFR §441.302(d), when an individual is determined to be likely to
require a level of care for this waiver, the individual or his or her legal representative is:
i. informed of any feasible alternatives under the waiver; and
ii. given the choice of either institutional or home and community-based services.
a. Procedures. Specify the State’s procedures for informing eligible individuals (or their legal
representatives) of the feasible alternatives available under the waiver and allowing these individuals to
choose either institutional or waiver services. Identify the form(s) that are employed to document freedom
of choice. The form or forms are available to CMS upon request through the Medicaid agency or the
operating agency (if applicable).

b. Maintenance of Forms. Per 45 CFR § 92.42, written copies or electronically retrievable facsimiles of
Freedom of Choice forms are maintained for a minimum of three years. Specify the locations where
copies of these forms are maintained.

State:
Effective Date

Appendix B-7: 1

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

State:
Effective Date

Appendix B-8: 1

Appendix C: Participant Services
HCBS Waiver Application Version 3.5

Appendix C: Participant Services
Appendix C-1/C-3: Summary of Services Covered and
Services Specifications
C-1-a. Waiver Services Summary. Appendix C-3 sets forth the specifications for each service that is offered
under this waiver. List the services that are furnished under the waiver in the following table. If case
management is not a service under the waiver, complete items C-1-b and C-1-c:

Statutory Services (check each that applies)
Service

Included

Case Management



Homemaker



Home Health Aide



Personal Care



Adult Day Health



Habilitation



Residential Habilitation



Day Habilitation



Prevocational Services



Supported Employment



Education



Respite



Day Treatment



Partial Hospitalization



Psychosocial Rehabilitation



Clinic Services



Live-in Caregiver
(42 CFR §441.303(f)(8))



Alternate Service Title (if any)

Other Services (select one)


Not applicable



As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following
additional services not specified in statute (list each service by title):

a.
b.
State:
Effective Date

Appendix C-1: 1

Appendix C: Participant Services
HCBS Waiver Application Version 3.5

c.
d.
e.
f.
g.
h.
i.
Extended State Plan Services (select one)


Not applicable



The following extended State plan services are provided (list each extended State plan service by
service title):

a.
b.
c.
Supports for Participant Direction (check each that applies))


The waiver provides for participant direction of services as specified in Appendix E. The waiver
includes Information and Assistance in Support of Participant Direction, Financial Management
Services or other supports for participant direction as waiver services.



The waiver provides for participant direction of services as specified in Appendix E. Some or all of
the supports for participant direction are provided as administrative activities and are described in
Appendix E.



Not applicable
Support

Included

Information and Assistance in
Support of Participant Direction



Financial Management Services



Alternate Service Title (if any)

Other Supports for Participant Direction (list each support by service title):
a.
b.
c.

State:
Effective Date

Appendix C-1: 2

Appendix C: Participant Services
HCBS Waiver Application Version 3.5

C-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request
through the Medicaid agency or the operating agency (if applicable).
Service Specification
HCBS Taxonomy
Category 1:

Sub-Category 1:

Category 2:

Sub-Category 2:

Category 3:

Sub-Category 3:

Category 4:

Sub-Category 4:

Service Definition (Scope):

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

Service Delivery Method
(check each that applies):



Specify whether the service may
be provided by (check each that
applies):
Provider
Category(s)
(check one or
both):



Participant-directed as specified in Appendix E



 Relative
Legally
Responsible
Person
Provider Specifications

Individual. List types:



Provider
managed

Legal Guardian

Agency. List the types of agencies:

Provider Qualifications
Provider Type:

License (specify)

Certificate (specify)

Other Standard (specify)

Verification of Provider Qualifications
Provider Type:

State:
Effective Date

Entity Responsible for Verification:

Frequency of Verification

Appendix C-1: 3

Appendix C: Participant Services
HCBS Waiver Application Version 3.5

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

Not applicable – Case management is not furnished as a distinct activity to waiver

participants.


Applicable – Case management is furnished as a distinct activity to waiver participants.

Check each that applies:


As a waiver service defined in Appendix C-3 (do not complete C-1-c)



As a Medicaid State plan service under §1915(i) of the Act (HCBS as a State Plan Option).
Complete item C-1-c.



As a Medicaid State plan service under §1915(g)(1) of the Act (Targeted Case
Management). Complete item C-1-c.



As an administrative activity. Complete item C-1-c.

c. Delivery of Case Management Services. Specify the entity or entities that conduct case management
functions on behalf of waiver participants:

State:
Effective Date

Appendix C-1: 4

Appendix C-2: General Service Specifications
a. Criminal History and/or Background Investigations. Specify the State’s policies concerning the
conduct of criminal history and/or background investigations of individuals who provide waiver services
(select one):



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



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

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

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



No. The State does not conduct abuse registry screening.

Services in Facilities Subject to §1616(e) of the Social Security Act. Select one:



No. Home and community-based services under this waiver are not provided in facilities subject
to §1616(e) of the Act. Do not complete Items C-2-c.i – c.iii.



Yes. Home and community-based services are provided in facilities subject to §1616(e) of the
Act. The standards that apply to each type of facility where waiver services are provided are
available to CMS upon request through the Medicaid agency or the operating agency (if
applicable). Complete Items C-2-c.i –c.iii.

Types of Facilities Subject to §1616(e). Complete the following table for each type of facility
subject to §1616(e) of the Act:
Type of Facility

State:
Effective Date

Waiver Service(s)
Provided in Facility

Facility Capacity
Limit

Appendix C-2: 1

ii. Larger Facilities: In the case of residential facilities subject to §1616(e) that serve four or more
individuals unrelated to the proprietor, describe how a home and community character is maintained in
these settings.

iii. Scope of Facility Standards. For this facility type, please specify whether the State’s standards
address the following (check each that applies):
Standard
Admission policies

Topic
Addressed


Physical environment



Sanitation



Safety



Staff : resident ratios



Staff training and qualifications



Staff supervision



Resident rights



Medication administration



Use of restrictive interventions



Incident reporting



Provision of or arrangement for
necessary health services



When facility standards do not address one or more of the topics listed, explain why the standard is
not included or is not relevant to the facility type or population. Explain how the health and welfare
of participants is assured in the standard area(s) not addressed:

State:
Effective Date

Appendix C-2: 2

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



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



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

Other State Policies Concerning Payment for Waiver Services Furnished by Relatives/Legal
Guardians. Specify State policies concerning making payment to relatives/legal guardians for the
provision of waiver services over and above the policies addressed in Item C-2-d. Select one:


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



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



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

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



State:
Effective Date

Other policy. Specify:

Appendix C-2: 3

Open Enrollment of Providers. Specify the processes that are employed to assure that all willing and
qualified providers have the opportunity to enroll as waiver service providers as provided in
42 CFR §431.51:

Quality Improvement: Qualified Providers
As a distinct component of the State’s quality improvement strategy, provide information in
the following fields to detail the State’s methods for discovery and remediation.
a.

Methods for Discovery: Qualified Providers
The state demonstrates that it has designed and implemented an adequate system for
assuring that all waiver services are provided by qualified providers.

Sub-Assurances:
a. Sub-Assurance: The State verifies that providers initially and continually meet required
licensure and/or certification standards and adhere to other standards prior to their
furnishing waiver services.
i. Performance Measures
For each performance measure the State will use to assess compliance with the statutory
assurance complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable
the State to analyze and assess progress toward the performance measure. In this section
provide information on the method by which each source of data is analyzed
statistically/deductively or inductively, how themes are identified or conclusions drawn, and
how recommendations are formulated, where appropriate.

Performance
Measure:
Data Source (Select one) (Several options are listed in the on-line application):
If ‘Other’ is selected, specify:

State:
Effective Date

Appendix C-2: 4

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

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

 State Medicaid Agency  Weekly
 Operating Agency
 Monthly
 Sub-State Entity

 Quarterly

 Other

 Annually

 100% Review
 Less than 100%
Review
 Representative
Sample; Confidence
Interval =

Specify:

 Continuously and

 Stratified:

Ongoing
 Other
Specify:

Describe Group:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

(check each that
applies
 Weekly
 Monthly
 Quarterly
 Annually

Specify:

 Continuously and
Ongoing
 Other
Specify:

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

Sub-Assurance: The State monitors non-licensed/non-certified providers to assure
adherence to waiver requirements.
i. Performance Measures

State:
Effective Date

Appendix C-2: 5

For each performance measure the State will use to assess compliance with the statutory
assurance complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable
the State to analyze and assess progress toward the performance measure. In this section
provide information on the method by which each source of data is analyzed
statistically/deductively or inductively, how themes are identified or conclusions drawn, and
how recommendations are formulated, where appropriate.
Performance
Measure:
Data Source (Select one) (Several options are listed in the on-line application):
If ‘Other’ is selected, specify:
Responsible Party for
data
collection/generation
(check each that
applies)

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

 State Medicaid Agency  Weekly
 Operating Agency
 Monthly
 Sub-State Entity

 Quarterly

 Other

 Annually

 100% Review
 Less than 100%
Review
 Representative
Sample; Confidence
Interval =

Specify:

 Continuously and

 Stratified:

Ongoing
 Other
Specify:

Describe Group:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

(check each that
applies
 Weekly
 Monthly
 Quarterly
 Annually

State:
Effective Date

Appendix C-2: 6

Specify:

 Continuously and
Ongoing

 Other
Specify:

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

Sub-Assurance: The State implements its policies and procedures for verifying that
provider training is conducted in accordance with state requirements and the approved
waiver.
i. Performance Measures
For each performance measure the State will use to assess compliance with the statutory
assurance complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable
the State to analyze and assess progress toward the performance measure. In this section
provide information on the method by which each source of data is analyzed
statistically/deductively or inductively, how themes are identified or conclusions drawn, and
how recommendations are formulated, where appropriate.
Performance
Measure:
Data Source (Select one) (Several options are listed in the on-line application):
If ‘Other’ is selected, specify:
Responsible Party for
data
collection/generation
(check each that
applies)

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

 State Medicaid Agency  Weekly
 Operating Agency
 Monthly
 Sub-State Entity

 Quarterly

 Other

 Annually

 100% Review
 Less than 100%
Review
 Representative
Sample; Confidence
Interval =

Specify:

State:
Effective Date

 Continuously and

 Stratified:

Ongoing

Describe Group:

Appendix C-2: 7

 Other
Specify:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

(check each that
applies
 Weekly
 Monthly
 Quarterly
 Annually

Specify:

 Continuously and
Ongoing
 Other
Specify:

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

Methods for Remediation/Fixing Individual Problems

State:
Effective Date

Appendix C-2: 8

Remediation Data Aggregation

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

Responsible Party (check

each that applies)

 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other: Specify:

Frequency of data
aggregation and
analysis:

(check each that
applies)
 Weekly
 Monthly
 Quarterly
 Annually
 Continuously and
Ongoing
 Other: Specify:

Timelines

When the State does not have all elements of the Quality Improvement Strategy in place,

provide timelines to design methods for discovery and remediation related to the assurance

of Qualified Providers that are currently non-operational.



Yes

Please provide a detailed strategy for assuring Qualified Providers, the
specific timeline for implementing identified strategies, and the parties
responsible for its operation.

State:
Effective Date

Appendix C-2: 9

Appendix C-4: Additional Limits on Amount of Waiver Services
Additional Limits on Amount of Waiver Services. Indicate whether the waiver employs any of the following
additional limits on the amount of waiver services (check each that applies).


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



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

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



Prospective Individual Budget Amount. There is a limit on the maximum dollar amount of waiver
services authorized for each specific participant. Furnish the information specified above.



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



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

State:
Effective Date

Appendix C-4: 1

Appendix C-5: Home and Community-Based Settings
Explain how residential and non-residential settings in this waiver comply with federal HCB
Settings requirements at 42 CFR 441.301(c)(4)-(5) and associated CMS guidance. Include:
1. Description of the settings and how they meet federal HCB Settings requirements, at the
time of submission and in the future.
2. Description of the means by which the state Medicaid agency ascertains that all waiver
settings meet federal HCB Setting requirements, at the time of this submission and ongoing.
Note instructions at Module 1, Attachment #2, HCB Settings Waiver Transition Plan for description
of settings that do not meet requirements at the time of submission. Do not duplicate that
information here.

State:
Effective Date

Appendix C-5: 1

Appendix D: Participant-Centered Planning and Service Delivery
HCBS Waiver Application Version 3.5

Appendix D: Participant-Centered Planning
and Service Delivery
Appendix D-1: Service Plan Development
State Participant-Centered Service Plan Title:
a. Responsibility for Service Plan Development. Per 42 CFR §441.301(b)(2), specify who is
responsible for the development of the service plan and the qualifications of these individuals (check
each that applies):


Registered nurse, licensed to practice in the State



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



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



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



Case Manager (qualifications not specified in Appendix C-1/C-3).
Specify qualifications:



Social Worker
Specify qualifications:



Other
Specify the individuals and their qualifications:

b. Service Plan Development Safeguards.
Select one:


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



Entities and/or individuals that have responsibility for service plan development may
provide other direct waiver services to the participant.
The State has established the following safeguards to ensure that service plan development
is conducted in the best interests of the participant. Specify:

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

Appendix D-1: 1

Appendix D: Participant-Centered Planning and Service Delivery
HCBS Waiver Application Version 3.5

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

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

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

g. Process for Making Service Plan Subject to the Approval of the Medicaid Agency. Describe the
process by which the service plan is made subject to the approval of the Medicaid agency in accordance
with 42 CFR §441.301(b)(1)(i):

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

Every three months or more frequently when necessary



Every six months or more frequently when necessary



Every twelve months or more frequently when necessary

State:
Effective Date

Appendix D-1: 2

Appendix D: Participant-Centered Planning and Service Delivery
HCBS Waiver Application Version 3.5



Other schedule
Specify the other schedule:

Maintenance of Service Plan Forms. Written copies or electronic facsimiles of service plans are
maintained for a minimum period of 3 years as required by 45 CFR §92.42. Service plans are
maintained by the following (check each that applies):


Medicaid agency



Operating agency



Case manager



Other
Specify:

State:
Effective Date

Appendix D-1: 3

Appendix D-2: Service Plan Implementation and Monitoring
a. Service Plan Implementation and Monitoring. Specify: (a) the entity (entities) responsible for
monitoring the implementation of the service plan and participant health and welfare; (b) the monitoring
and follow-up method(s) that are used; and, (c) the frequency with which monitoring is performed.

b. Monitoring Safeguards. Select one:


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



Entities and/or individuals that have responsibility to monitor service plan implementation
and participant health and welfare may provide other direct waiver services to the
participant.
The State has established the following safeguards to ensure that monitoring is conducted in the
best interests of the participant. Specify:

Quality Improvement: Service Plan
As a distinct component of the State’s quality improvement strategy, provide information in
the following fields to detail the State’s methods for discovery and remediation.
a.

Methods for Discovery: Service Plan Assurance
The state demonstrates it has designed and implemented an effective system for reviewing
the adequacy of service plans for waiver participants.

i. Sub-assurances:
a. Sub-assurance: Service plans address all participants’ assessed needs (including health
and safety risk factors) and personal goals, either by the provision of waiver services or
through other means.
i. Performance Measures
State:
Effective Date

Appendix D-2: 1

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

 State Medicaid Agency  Weekly
 Operating Agency
 Monthly
 Sub-State Entity

 Quarterly

 Other

 Annually

 100% Review
 Less than 100%
Review
 Representative
Sample; Confidence
Interval =

Specify:

 Continuously and

 Stratified:

Ongoing
 Other
Specify:

Describe Group:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

(check each that
applies
 Weekly
 Monthly
 Quarterly
 Annually

State:
Effective Date

Appendix D-2: 2

Specify:

 Continuously and
Ongoing

 Other
Specify:

Add another Performance measure (button to prompt another performance measure)
b.Sub-assurance: The State monitors service plan development in accordance with its
policies and procedures.
i. Performance Measures
For each performance measure the State will use to assess compliance with the statutory
assurance complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable
the State to analyze and assess progress toward the performance measure. In this section
provide information on the method by which each source of data is analyzed
statistically/deductively or inductively, how themes are identified or conclusions drawn, and
how recommendations are formulated, where appropriate.
Performance
Measure:
Data Source (Select one) (Several options are listed in the on-line application):
If ‘Other’ is selected, specify:
Responsible Party for
data
collection/generation
(check each that
applies)

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

 State Medicaid Agency  Weekly
 Operating Agency
 Monthly
 Sub-State Entity

 Quarterly

 Other

 Annually

 100% Review
 Less than 100%
Review
 Representative
Sample; Confidence
Interval =

Specify:

State:
Effective Date

 Continuously and

 Stratified:

Ongoing
 Other

Describe Group:

Appendix D-2: 3

Specify:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

(check each that
applies
 Weekly
 Monthly
 Quarterly
 Annually

Specify:

 Continuously and
Ongoing
 Other
Specify:

Add another Performance measure (button to prompt another performance measure)
c.
Sub-assurance: Service plans are updated/revised at least annually or when
warranted by changes in the waiver participant’s needs.
i. Performance Measures
For each performance measure the State will use to assess compliance with the statutory
assurance complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable
the State to analyze and assess progress toward the performance measure. In this section
provide information on the method by which each source of data is analyzed
statistically/deductively or inductively, how themes are identified or conclusions drawn, and
how recommendations are formulated, where appropriate.
Performance
Measure:
Data Source (Select one) (Several options are listed in the on-line application):
If ‘Other’ is selected, specify:

State:
Effective Date

Appendix D-2: 4

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

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

 State Medicaid Agency  Weekly
 Operating Agency
 Monthly
 Sub-State Entity

 Quarterly

 Other

 Annually

 100% Review
 Less than 100%
Review
 Representative
Sample; Confidence
Interval =

Specify:

 Continuously and

 Stratified:

Ongoing
 Other
Specify:

Describe Group:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

(check each that
applies
 Weekly
 Monthly
 Quarterly
 Annually

Specify:

 Continuously and
Ongoing
 Other
Specify:

Add another Performance measure (button to prompt another performance measure)
d.
Sub-assurance: Services are delivered in accordance with the service plan,
including the type, scope, amount, duration and frequency specified in the service plan.
i. Performance Measures

State:
Effective Date

Appendix D-2: 5

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

 State Medicaid Agency  Weekly
 Operating Agency
 Monthly
 Sub-State Entity

 Quarterly

 Other

 Annually

 100% Review
 Less than 100%
Review
 Representative
Sample; Confidence
Interval =

Specify:

 Continuously and

 Stratified:

Ongoing
 Other
Specify:

Describe Group:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

(check each that
applies
 Weekly
 Monthly
 Quarterly
 Annually

Specify:
State:
Effective Date

Appendix D-2: 6

 Continuously and
Ongoing
 Other
Specify:

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

Sub-assurance: Participants are afforded choice between/among waiver services and
providers.
i. Performance Measures
For each performance measure the State will use to assess compliance with the statutory
assurance complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable
the State to analyze and assess progress toward the performance measure. In this section
provide information on the method by which each source of data is analyzed
statistically/deductively or inductively, how themes are identified or conclusions drawn, and
how recommendations are formulated, where appropriate.

Performance
Measure:
Data Source (Select one) (Several options are listed in the on-line application):
If ‘Other’ is selected, specify:
Responsible Party for
data
collection/generation
(check each that
applies)

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

 State Medicaid Agency  Weekly
 Operating Agency
 Monthly
 Sub-State Entity

 Quarterly

 Other

 Annually

 100% Review
 Less than 100%
Review
 Representative
Sample; Confidence
Interval =

Specify:

State:
Effective Date

 Continuously and

 Stratified:

Ongoing
 Other

Describe Group:

Appendix D-2: 7

Specify:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

(check each that
applies
 Weekly
 Monthly
 Quarterly
 Annually

Specify:

 Continuously and
Ongoing
 Other
Specify:

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

Methods for Remediation/Fixing Individual Problems

State:
Effective Date

Appendix D-2: 8

ii.

Remediation Data Aggregation

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

Responsible Party (check

each that applies):

Frequency of data
aggregation and
analysis

(check each that
applies):
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other
Specify:

 Weekly
 Monthly
 Quarterly
 Annually
 Continuously and
Ongoing
 Other
Specify:

Timelines

When the State does not have all elements of the Quality Improvement Strategy in place,

provide timelines to design methods for discovery and remediation related to the assurance

of Service Plans that are currently non-operational.



Yes

Please provide a detailed strategy for assuring Service Plans, the specific timeline for
implementing identified strategies, and the parties responsible for its operation.

State:
Effective Date

Appendix D-2: 9

Appendix E: Participant Direction of Services
HCBS Waiver Application Version 3.5

Appendix E: Participant Direction of Services
Applicability (from Application Section 3, Components of the Waiver Request):


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



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

CMS urges states to afford all waiver participants the opportunity to direct their services. Participant
direction of services includes the participant exercising decision-making authority over workers who provide
services, a participant-managed budget or both. CMS will confer the Independence Plus designation when
the waiver evidences a strong commitment to participant direction.
Indicate whether Independence Plus designation is requested (select one):


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



No. Independence Plus designation is not requested.

Appendix E-1: Overview
a. Description of Participant Direction. In no more than two pages, provide an overview of the
opportunities for participant direction in the waiver, including: (a) the nature of the opportunities afforded
to participants; (b) how participants may take advantage of these opportunities; (c) the entities that support
individuals who direct their services and the supports that they provide; and, (d) other relevant information
about the waiver’s approach to participant direction.

Participant Direction Opportunities. Specify the participant direction opportunities that are available
in the waiver. Select one:


Participant – Employer Authority. As specified in Appendix E-2, Item a, the participant
(or the participant’s representative) has decision-making authority over workers who provide
waiver services. The participant may function as the common law employer or the coemployer of workers. Supports and protections are available for participants who exercise
this authority.



Participant – Budget Authority. As specified in Appendix E-2, Item b, the participant (or
the participant’s representative) has decision-making authority over a budget for waiver
services. Supports and protections are available for participants who have authority over a
budget.



Both Authorities. The waiver provides for both participant direction opportunities as
specified in Appendix E-2. Supports and protections are available for participants who
exercise these authorities.

State:
Effective Date

Appendix E-1: 1

Appendix E: Participant Direction of Services
HCBS Waiver Application Version 3.5

Availability of Participant Direction by Type of Living Arrangement. Check each that applies:


Participant direction opportunities are available to participants who live in their own
private residence or the home of a family member.



Participant direction opportunities are available to individuals who reside in other living
arrangements where services (regardless of funding source) are furnished to fewer than
four persons unrelated to the proprietor.



The participant direction opportunities are available to persons in the following other
living arrangements
Specify these living arrangements:

Election of Participant Direction. Election of participant direction is subject to the following policy
(select one):


Waiver is designed to support only individuals who want to direct their services.



The waiver is designed to afford every participant (or the participant’s representative)
the opportunity to elect to direct waiver services. Alternate service delivery methods
are available for participants who decide not to direct their services.



The waiver is designed to offer participants (or their representatives) the opportunity
to direct some or all of their services, subject to the following criteria specified by the
State. Alternate service delivery methods are available for participants who decide not
to direct their services or do not meet the criteria.
Specify the criteria

Information Furnished to Participant. Specify: (a) the information about participant direction
opportunities (e.g., the benefits of participant direction, participant responsibilities, and potential
liabilities) that is provided to the participant (or the participant’s representative) to inform decisionmaking concerning the election of participant direction; (b) the entity or entities responsible for furnishing
this information; and, (c) how and when this information is provided on a timely basis.

Participant Direction by a Representative. Specify the State’s policy concerning the direction of
waiver services by a representative (select one):


The State does not provide for the direction of waiver services by a representative.



The State provides for the direction of waiver services by representatives.
Specify the representatives who may direct waiver services: (check each that applies):

State:
Effective Date



Waiver services may be directed by a legal representative of the participant.



Waiver services may be directed by a non-legal representative freely chosen by
an adult participant. Specify the policies that apply regarding the direction of waiver
services by participant-appointed representatives, including safeguards to ensure that
the representative functions in the best interest of the participant:

Appendix E-1: 2

Appendix E: Participant Direction of Services
HCBS Waiver Application Version 3.5

g. Participant-Directed Services. Specify the participant direction opportunity (or opportunities) available
for each waiver service that is specified as participant-directed in Appendix C-1/C-3. (Check the
opportunity or opportunities available for each service):
Participant-Directed Waiver Service

Employer
Authority

Budget
Authority



h. Financial Management Services. Except in certain circumstances, financial management services are
mandatory and integral to participant direction. A governmental entity and/or another third-party entity
must perform necessary financial transactions on behalf of the waiver participant. Select one:
 Yes. Financial Management Services are furnished through a third party entity. (Complete
item E-1-i).
Specify whether governmental and/or private entities furnish these services. Check each that
applies:
 Governmental entities
 Private entities
 No. Financial Management Services are not furnished.
mechanisms are used. Do not complete Item E-1-i.
i.

Standard Medicaid payment

Provision of Financial Management Services. Financial management services (FMS) may be furnished
as a waiver service or as an administrative activity. Select one:


FMS are covered as the waiver service
specified in Appendix C-1/C-3
The waiver service entitled:



FMS are provided as an administrative activity.
Provide the following information

Types of Entities: Specify the types of entities that furnish FMS and the method of procuring
these services:

ii.

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

iii.

Scope of FMS. Specify the scope of the supports that FMS entities provide (check each that
applies):

State:
Effective Date

Appendix E-1: 3

Appendix E: Participant Direction of Services
HCBS Waiver Application Version 3.5

Supports furnished when the participant is the employer of direct support workers:



Assists participant in verifying support worker citizenship status




Collects and processes timesheets of support workers



Processes payroll, withholding, filing and payment of applicable federal, state and
local employment-related taxes and insurance
Other
Specify:

Supports furnished when the participant exercises budget authority:




Maintains a separate account for each participant’s participant-directed budget




Processes and pays invoices for goods and services approved in the service plan



Tracks and reports participant funds, disbursements and the balance of participant
funds
Provide participant with periodic reports of expenditures and the status of the
participant-directed budget
Other services and supports
Specify:

Additional functions/activities:

iv.

State:
Effective Date



Executes and holds Medicaid provider agreements as authorized under a written
agreement with the Medicaid agency



Receives and disburses funds for the payment of participant-directed services under
an agreement with the Medicaid agency or operating agency



Provides other entities specified by the State with periodic reports of expenditures
and the status of the participant-directed budget



Other
Specify:

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

Appendix E-1: 4

Appendix E: Participant Direction of Services
HCBS Waiver Application Version 3.5

Information and Assistance in Support of Participant Direction. In addition to financial management
services, participant direction is facilitated when information and assistance are available to support
participants in managing their services. These supports may be furnished by one or more entities,
provided that there is no duplication. Specify the payment authority (or authorities) under which these
supports are furnished and, where required, provide the additional information requested (check each that
applies):


Case Management Activity. Information and assistance in support of participant direction are
furnished as an element of Medicaid case management services.
Specify in detail the information and assistance that are furnished through case management for
each participant direction opportunity under the waiver:



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

Information and Assistance Provided through
this Waiver Service Coverage

(list of services from Appendix C-1/C-3)




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

Independent Advocacy (select one).


No. Arrangements have not been made for independent advocacy.



Yes. Independent advocacy is available to participants who direct their services.
Describe the nature of this independent advocacy and how participants may access this advocacy:

Voluntary Termination of Participant Direction. Describe how the State accommodates a participant
who voluntarily terminates participant direction in order to receive services through an alternate service
delivery method, including how the State assures continuity of services and participant health and welfare
during the transition from participant direction:

m. Involuntary Termination of Participant Direction. Specify the circumstances when the State will
involuntarily terminate the use of participant direction and require the participant to receive providermanaged services instead, including how continuity of services and participant health and welfare is
assured during the transition.
State:
Effective Date

Appendix E-1: 5

Appendix E: Participant Direction of Services
HCBS Waiver Application Version 3.5

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

Waiver Year

Employer Authority Only

Budget Authority Only or
Budget Authority in
Combination with Employer
Authority

Number of Participants

Year 1
Year 2
Year 3
Year 4 (only appears if
applicable based on Item 1
C)
Year 5 (only appears if
applicable based on Item 1
C)

State:
Effective Date

Appendix E-1: 6

Appendix E-2: Opportunities for Participant-Direction
a. Participant – Employer Authority Complete when the waiver offers the employer authority opportunity
as indicated in Item E-1-b:
i. Participant Employer Status. Specify the participant’s employer status under the waiver. Select
one or both:


Participant/Co-Employer. The participant (or the participant’s representative)
functions as the co-employer (managing employer) of workers who provide waiver
services. An agency is the common law employer of participant-selected/recruited staff
and performs necessary payroll and human resources functions. Supports are available
to assist the participant in conducting employer-related functions.
Specify the types of agencies (a.k.a., “agencies with choice”) that serve as co-employers
of participant-selected staff:



Participant/Common Law Employer.
The participant (or the participant’s
representative) is the common law employer of workers who provide waiver services.
An IRS-approved Fiscal/Employer Agent functions as the participant’s agent in
performing payroll and other employer responsibilities that are required by federal and
state law. Supports are available to assist the participant in conducting employer-related
functions.

ii. Participant Decision Making Authority. The participant (or the participant’s representative) has
decision making authority over workers who provide waiver services. Select one or more decision
making authorities that participants exercise:







Recruit staff
Refer staff to agency for hiring (co-employer)
Select staff from worker registry
Hire staff (common law employer)
Verify staff qualifications
Obtain criminal history and/or background investigation of staff
Specify how the costs of such investigations are compensated:



Specify additional staff qualifications based on participant needs and preferences so
long as such qualifications are consistent with the qualifications specified in Appendix
C-1/C-3.
Determine staff duties consistent with the service specifications in Appendix C-1/C
3.
Determine staff wages and benefits subject to applicable State limits
Schedule staff
Orient and instruct staff in duties
Supervise staff
Evaluate staff performance
Verify time worked by staff and approve time sheets
Discharge staff (common law employer)









State:
Effective Date

Appendix E-2: 1



Discharge staff from providing services (co-employer)



Other
Specify:

b. Participant – Budget Authority Complete when the waiver offers the budget authority opportunity as
indicated in Item E-1-b:
i.

Participant Decision Making Authority. When the participant has budget authority, indicate the
decision-making authority that the participant may exercise over the budget. Select one or more:


Reallocate funds among services included in the budget



Determine the amount paid for services within the State’s established limits



Substitute service providers



Schedule the provision of services



Specify additional service provider qualifications consistent with the qualifications
specified in Appendix C-1/C-3



Specify how services are provided, consistent with the service specifications
contained in Appendix C-1/C-3



Identify service providers and refer for provider enrollment



Authorize payment for waiver goods and services



Review and approve provider invoices for services rendered



Other
Specify:

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

iii. Informing Participant of Budget Amount. Describe how the State informs each participant of the
amount of the participant-directed budget and the procedures by which the participant may request
an adjustment in the budget amount.

State:
Effective Date

Appendix E-2: 2

iv. Participant Exercise of Budget Flexibility. Select one:


Modifications to the participant directed budget must be preceded by a change in the
service plan.



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

v. Expenditure Safeguards. Describe the safeguards that have been established for the timely
prevention of the premature depletion of the participant-directed budget or to address potential
service delivery problems that may be associated with budget underutilization and the entity (or
entities) responsible for implementing these safeguards:

State:
Effective Date

Appendix E-2: 3

Appendix F: Participant Rights
HCBS Waiver Application Version 3.5

Appendix F: Participant Rights
Appendix F-1: Opportunity to Request a Fair Hearing
The State provides an opportunity to request a Fair Hearing under 42 CFR Part 431, Subpart E to individuals:
(a) who are not given the choice of home and community-based services as an alternative to the institutional
care specified in Item 1-F of the request; (b) are denied the service(s) of their choice or the provider(s) of their
choice; or, (c) whose services are denied, suspended, reduced or terminated. The State provides notice of
action as required in 42 CFR §431.210.
Procedures for Offering Opportunity to Request a Fair Hearing. Describe how the individual (or his/her
legal representative) is informed of the opportunity to request a fair hearing under 42 CFR Part 431, Subpart
E. Specify the notice(s) that are used to offer individuals the opportunity to request a Fair Hearing. State laws,
regulations, policies and notices referenced in the description are available to CMS upon request through the
operating or Medicaid agency.

State:
Effective Date

Appendix F-1: 1

Appendix F-2: Additional Dispute Resolution Process
a. Availability of Additional Dispute Resolution Process. Indicate whether the State operates another
dispute resolution process that offers participants the opportunity to appeal decisions that adversely affect
their services while preserving their right to a Fair Hearing. Select one:


No. This Appendix does not apply



Yes. The State operates an additional dispute resolution process

b. Description of Additional Dispute Resolution Process. Describe the additional dispute resolution
process, including: (a) the State agency that operates the process; (b) the nature of the process
(i.e., procedures and timeframes), including the types of disputes addressed through the process; and, (c)
how the right to a Medicaid Fair Hearing is preserved when a participant elects to make use of the process:
State laws, regulations, and policies referenced in the description are available to CMS upon request
through the operating or Medicaid agency.

State:
Effective Date

Appendix F-2: 1

Appendix F-3: State Grievance/Complaint System
a.

Operation of Grievance/Complaint System. Select one:


No. This Appendix does not apply



Yes. The State operates a grievance/complaint system that affords participants the
opportunity to register grievances or complaints concerning the provision of services
under this waiver

Operational Responsibility. Specify the State agency that is responsible for the operation of the
grievance/complaint system:

Description of System. Describe the grievance/complaint system, including: (a) the types of
grievances/complaints that participants may register; (b) the process and timelines for addressing
grievances/complaints; and, (c) the mechanisms that are used to resolve grievances/complaints. State
laws, regulations, and policies referenced in the description are available to CMS upon request through
the Medicaid agency or the operating agency (if applicable).

State:
Effective Date

Appendix F-3: 1

Appendix G: Participant Safeguards
HCBS Waiver Application Version 3.5

Appendix G: Participant Safeguards
Appendix G-1: Response to Critical Events or Incidents
a. Critical Event or Incident Reporting and Management Process. Indicate whether the State
operates Critical Event or Incident Reporting and Management Process that enables the State to collect
information on sentinel events occurring in the waiver program. Select one:


Yes. The State operates a Critical Event or Incident Reporting and Management
Process (complete Items b through e)



No. This Appendix does not apply (do not complete Items b through e).
If the State does not operate a Critical Event or Incident Reporting and Management
Process, describe the process that the State uses to elicit information on the health and
welfare of individuals served through the program.

b. State Critical Event or Incident Reporting Requirements. Specify the types of critical events or
incidents (including alleged abuse, neglect and exploitation) that the State requires to be reported for
review and follow-up action by an appropriate authority, the individuals and/or entities that are
required to report such events and incidents, and the timelines for reporting. State laws, regulations,
and policies that are referenced are available to CMS upon request through the Medicaid agency or
the operating agency (if applicable).

Participant Training and Education. Describe how training and/or information is provided to
participants (and/or families or legal representatives, as appropriate) concerning protections from
abuse, neglect, and exploitation, including how participants (and/or families or legal representatives,
as appropriate) can notify appropriate authorities or entities when the participant may have experienced
abuse, neglect or exploitation.

d. Responsibility for Review of and Response to Critical Events or Incidents. Specify the entity (or
entities) that receives reports of critical events or incidents specified in item G-1-a, the methods that
are employed to evaluate such reports, and the processes and time-frames for responding to critical
events or incidents, including conducting investigations.

State:
Effective Date

Appendix G-1: 1

Appendix G: Participant Safeguards
HCBS Waiver Application Version 3.5

Responsibility for Oversight of Critical Incidents and Events. Identify the State agency (or
agencies) responsible for overseeing the reporting of and response to critical incidents or events that
affect waiver participants, how this oversight is conducted, and how frequently.

State:
Effective Date

Appendix G-1: 2

Appendix G: Participant Safeguards
HCBS Waiver Application Version 3.5

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

 The use of restraints is permitted during the course of the delivery of waiver services.
Complete Items G-2-a-i and G-2-a-ii:
i.

Safeguards Concerning the Use of Restraints. Specify the safeguards that the State has
established concerning the use of each type of restraint (i.e., personal restraints, drugs used as
restraints, mechanical restraints). State laws, regulations, and policies that are referenced are
available to CMS upon request through the Medicaid agency or the operating agency (if
applicable).

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

Use of Restrictive Interventions
 The State does not permit or prohibits the use of restrictive interventions
Specify the State agency (or agencies) responsible for detecting the unauthorized use of
restrictive interventions and how this oversight is conducted and its frequency:

 The use of restrictive interventions is permitted during the course of the delivery of
waiver services. Complete Items G-2-b-i and G-2-b-ii.

State:
Effective Date

Appendix G-2: 1

Appendix G: Participant Safeguards
HCBS Waiver Application Version 3.5

Safeguards Concerning the Use of Restrictive Interventions. Specify the safeguards that the
State has in effect concerning the use of interventions that restrict participant movement,
participant access to other individuals, locations or activities, restrict participant rights or employ
aversive methods (not including restraints or seclusion) to modify behavior. State laws,
regulations, and policies referenced in the specification are available to CMS upon request
through the Medicaid agency or the operating agency.

ii. State Oversight Responsibility. Specify the State agency (or agencies) responsible for
monitoring and overseeing the use of restrictive interventions and how this oversight is conducted
and its frequency:

Use of Seclusion. (Select one): (This section will be blank for waivers submitted before Appendix G2-c was added to WMS in March 2014, and responses for seclusion will display in Appendix G-2-a
combined with information on restraints.)
 The State does not permit or prohibits the use of seclusion
Specify the State agency (or agencies) responsible for detecting the unauthorized use of
seclusion and how this oversight is conducted and its frequency:

 The use of seclusion is permitted during the course of the delivery of waiver services.
Complete Items G-2-c-i and G-2-c-ii.
i.

Safeguards Concerning the Use of Seclusion. Specify the safeguards that the State has
established concerning the use of each type of seclusion. State laws, regulations, and policies that
are referenced in the specification are available to CMS upon request through the Medicaid
agency or the operating agency (if applicable).

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

State:
Effective Date

Appendix G-2: 2

Appendix G-3: Medication Management and Administration
This Appendix must be completed when waiver services are furnished to participants who are served in licensed
or unlicensed living arrangements where a provider has round-the-clock responsibility for the health and
welfare of residents. The Appendix does not need to be completed when waiver participants are served
exclusively in their own personal residences or in the home of a family member.
a. Applicability. Select one:


No. This Appendix is not applicable (do not complete the remaining items)



Yes. This Appendix applies (complete the remaining items)

b. Medication Management and Follow-Up
i.

Responsibility. Specify the entity (or entities) that have ongoing responsibility for monitoring
participant medication regimens, the methods for conducting monitoring, and the frequency of
monitoring.

ii. Methods of State Oversight and Follow-Up. Describe: (a) the method(s) that the State uses to
ensure that participant medications are managed appropriately, including: (a) the identification of
potentially harmful practices (e.g., the concurrent use of contraindicated medications); (b) the
method(s) for following up on potentially harmful practices; and (c) the State agency (or agencies)
that is responsible for follow-up and oversight.

Medication Administration by Waiver Providers
i.

Provider Administration of Medications. Select one:


Not applicable (do not complete the remaining items)



Waiver providers are responsible for the administration of medications to waiver
participants who cannot self-administer and/or have responsibility to oversee
participant self-administration of medications. (complete the remaining items)

ii. State Policy. Summarize the State policies that apply to the administration of medications by waiver
providers or waiver provider responsibilities when participants self-administer medications,
including (if applicable) policies concerning medication administration by non-medical waiver
provider personnel. State laws, regulations, and policies referenced in the specification are available
to CMS upon request through the Medicaid agency or the operating agency (if applicable).

State:
Effective Date

Appendix G-3: 1

iii. Medication Error Reporting. Select one of the following:


Providers that are responsible for medication administration are required to both
record and report medication errors to a State agency (or agencies). Complete the
following three items:
(a) Specify State agency (or agencies) to which errors are reported:

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



Providers responsible for medication administration are required to record
medication errors but make information about medication errors available only
when requested by the State.
Specify the types of medication errors that providers are required to record:

iv. State Oversight Responsibility. Specify the State agency (or agencies) responsible for monitoring
the performance of waiver providers in the administration of medications to waiver participants and
how monitoring is performed and its frequency.

Quality Improvement: Health and Welfare
As a distinct component of the State’s quality improvement strategy, provide information in
the following fields to detail the State’s methods for discovery and remediation.
a.

Methods for Discovery: Health and Welfare
The State demonstrates it has designed and implemented an effective system for assuring
waiver participant health and welfare. (For waiver actions submitted before June 1, 2014,
this assurance read “The State, on an ongoing basis, identifies, addresses, and seeks to
prevent the occurrence of abuse, neglect and exploitation.”)

Sub-assurances:

State:
Effective Date

Appendix G-3: 2

a. Sub-assurance: The state demonstrates on an ongoing basis that it identifies, addresses
and seeks to prevent instances of abuse, neglect, exploitation and unexplained death.
(Performance measures in this sub-assurance include all Appendix G performance
measures for waiver actions submitted before June 1, 2014.)
i.

Performance Measures
For each performance measure the State will use to assess compliance with the statutory
assurance complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable
the State to analyze and assess progress toward the performance measure. In this section
provide information on the method by which each source of data is analyzed
statistically/deductively or inductively, how themes are identified or conclusions drawn, and
how recommendations are formulated, where appropriate.

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

 State Medicaid Agency  Weekly
 Operating Agency
 Monthly
 Sub-State Entity

 Quarterly

 Other

 Annually

 100% Review
 Less than 100%
Review
 Representative
Sample; Confidence
Interval =

Specify:

 Continuously and

 Stratified:

Ongoing
 Other
Specify:

Describe Group:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis
State:
Effective Date

Frequency of data
aggregation and
analysis:

Appendix G-3: 3

(check each that
applies
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

(check each that
applies
 Weekly
 Monthly
 Quarterly
 Annually

Specify:

 Continuously and
Ongoing
 Other
Specify:

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

Sub-assurance: The State demonstrates that an incident management system is in place
that effectively resolves those incidents and prevents further similar incidents to the extent
possible.
For each performance measure the State will use to assess compliance with the statutory
assurance (or sub-assurance), complete the following. Where possible, include
numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable
the State to analyze and assess progress toward the performance measure. In this section
provide information on the method by which each source of data is analyzed
statistically/deductively or inductively, how themes are identified or conclusions drawn, and
how recommendations are formulated, where appropriate.

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

 State Medicaid Agency  Weekly
 Operating Agency
 Monthly

 100% Review
 Less than 100%
Review

State:
Effective Date

Appendix G-3: 4

 Sub-State Entity

 Quarterly

 Representative
Sample; Confidence
Interval =

 Other

 Annually

Specify:

 Continuously and

 Stratified:

Ongoing

Describe Group:

 Other
Specify:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

(check each that
applies
 Weekly
 Monthly
 Quarterly
 Annually

Specify:

 Continuously and
Ongoing
 Other
Specify:

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

Sub-assurance: The State policies and procedures for the use or prohibition of restrictive
interventions (including restraints and seclusion) are followed.
For each performance measure the State will use to assess compliance with the statutory
assurance (or sub-assurance), complete the following. Where possible, include
numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable
the State to analyze and assess progress toward the performance measure. In this section
provide information on the method by which each source of data is analyzed
statistically/deductively or inductively, how themes are identified or conclusions drawn, and
how recommendations are formulated, where appropriate.

Performance
Measure:
State:
Effective Date

Appendix G-3: 5

Data Source (Select one) (Several options are listed in the on-line application):
If ‘Other’ is selected, specify:
Responsible Party for
data
collection/generation
(check each that
applies)

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

 State Medicaid Agency  Weekly
 Operating Agency
 Monthly
 Sub-State Entity

 Quarterly

 Other

 Annually

 100% Review
 Less than 100%
Review
 Representative
Sample; Confidence
Interval =

Specify:

 Continuously and

 Stratified:

Ongoing
 Other
Specify:

Describe Group:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

(check each that
applies
 Weekly
 Monthly
 Quarterly
 Annually

Specify:

 Continuously and
Ongoing
 Other
Specify:

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

State:
Effective Date

Appendix G-3: 6

Sub-assurance: The State establishes overall health care standards and monitors those
standards based on the responsibility of the service provider as stated in the approved
waiver.
For each performance measure the State will use to assess compliance with the statutory
assurance (or sub-assurance), complete the following. Where possible, include
numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable
the State to analyze and assess progress toward the performance measure. In this section
provide information on the method by which each source of data is analyzed
statistically/deductively or inductively, how themes are identified or conclusions drawn, and
how recommendations are formulated, where appropriate.

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

 State Medicaid Agency  Weekly
 Operating Agency
 Monthly
 Sub-State Entity

 Quarterly

 Other

 Annually

 100% Review
 Less than 100%
Review
 Representative
Sample; Confidence
Interval =

Specify:

 Continuously and

 Stratified:

Ongoing
 Other
Specify:

Describe Group:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies

State:
Effective Date

Appendix G-3: 7

 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

 Weekly
 Monthly
 Quarterly
 Annually

Specify:

 Continuously and
Ongoing

 Other
Specify:

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

ii.

Methods for Remediation/Fixing Individual Problems

ii.

Remediation Data Aggregation
Responsible Party (check

each that applies):

Frequency of data
aggregation and
analysis

(check each that
applies)
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
State:
Effective Date

 Weekly
 Monthly
 Quarterly

Appendix G-3: 8

 Other
Specify:

 Annually
 Continuously and
Ongoing
 Other
Specify:

Timelines

When the State does not have all elements of the Quality Improvement Strategy in place,

provide timelines to design methods for discovery and remediation related to the assurance

of Health and Welfare that are currently non-operational.



Yes

Please provide a detailed strategy for assuring Health and Welfare, the specific timeline for
implementing identified strategies, and the parties responsible for its operation.

State:
Effective Date

Appendix G-3: 9

Appendix H: Quality Improvement Strategy
HCBS Waiver Application Version 3.5

Appendix H: Quality Improvement Strategy
Under §1915(c) of the Social Security Act and 42 CFR §441.302, the approval of an HCBS waiver
requires that CMS determine that the State has made satisfactory assurances concerning the protection
of participant health and welfare, financial accountability and other elements of waiver operations.
Renewal of an existing waiver is contingent upon review by CMS and a finding by CMS that the
assurances have been met. By completing the HCBS waiver application, the State specifies how it has
designed the waiver’s critical processes, structures and operational features in order to meet these
assurances.
• Quality Improvement is a critical operational feature that an organization employs to continually
determine whether it operates in accordance with the approved design of its program, meets statutory
and regulatory assurances and requirements, achieves desired outcomes, and identifies opportunities
for improvement.
CMS recognizes that a state’s waiver Quality Improvement Strategy may vary depending on the nature of
the waiver target population, the services offered, and the waiver’s relationship to other public programs,
and will extend beyond regulatory requirements. However, for the purpose of this application, the State is
expected to have, at the minimum, systems in place to measure and improve its own performance in
meeting six specific waiver assurances and requirements.
It may be more efficient and effective for a Quality Improvement Strategy to span multiple waivers and
other long-term care services. CMS recognizes the value of this approach and will ask the state to identify
other waiver programs and long-term care services that are addressed in the Quality Improvement
Strategy.

State:
Effective Date

Appendix H: 1

Appendix H: Quality Improvement Strategy
HCBS Waiver Application Version 3.5

Quality Improvement Strategy: Minimum Components
The Quality Improvement Strategy that will be in effect during the period of the approved waiver is described
throughout the waiver in the appendices corresponding to the statutory assurances and sub-assurances. Other
documents cited must be available to CMS upon request through the Medicaid agency or the operating agency
(if appropriate).

In the QIS discovery and remediation sections throughout the application (located in Appendices A,
B, C, D, G, and I), a state spells out:
•

The evidence based discovery activities that will be conducted for each of the six major waiver
assurances;
• The remediation activities followed to correct individual problems identified in the
implementation of each of the assurances;
In Appendix H of the application, a State describes (1) the system improvement activities followed
in response to aggregated, analyzed discovery and remediation information collected on each of the
assurances; (2) the correspondent roles/responsibilities of those conducting assessing and
prioritizing improving system corrections and improvements; and (3) the processes the state will
follow to continuously assess the effectiveness of the QIS and revise it as necessary and appropriate.
If the State's Quality Improvement Strategy is not fully developed at the time the waiver application is
submitted, the state may provide a work plan to fully develop its Quality Improvement Strategy, including the
specific tasks the State plans to undertake during the period the waiver is in effect, the major milestones
associated with these tasks, and the entity (or entities) responsible for the completion of these tasks.
When the Quality Improvement Strategy spans more than one waiver and/or other types of long-term care
services under the Medicaid State plan, specify the control numbers for the other waiver programs and/or
identify the other long-term services that are addressed in the Quality Improvement Strategy. In instances when
the QMS spans more than one waiver, the State must be able to stratify information that is related to each
approved waiver program. Unless the State has requested and received approval from CMS for the
consolidation of multiple waivers for the purpose of reporting, then the State must stratify information that is
related to each approved waiver program, i.e., employ a representative sample for each waiver.

State:
Effective Date

Appendix H: 2

Appendix H: Quality Improvement Strategy
HCBS Waiver Application Version 3.5

H.1

Systems Improvement

System Improvements
i.
Describe the process(es) for trending, prioritizing and implementing system
improvements (i.e., design changes) prompted as a result of an analysis of discovery
and remediation information.

ii.

System Improvement Activities
Frequency of monitoring and
Responsible Party (check each
analysis
that applies):
(check each that applies):
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Quality Improvement
Committee
 Other
Specify:

 Weekly
 Monthly
 Quarterly
 Annually
 Other
Specify:

System Design Changes
i.
Describe the process for monitoring and analyzing the effectiveness of system design
changes. Include a description of the various roles and responsibilities involved in
the processes for monitoring & assessing system design changes. If applicable,
include the State’s targeted standards for systems improvement.

ii.

State:
Effective Date

Describe the process to periodically evaluate, as appropriate, the Quality
Improvement Strategy.

Appendix H: 3

Appendix I: Financial Accountability
HCBS Waiver Application Version 3.5

Appendix I: Financial Accountability
APPENDIX I-1: Financial Integrity and Accountability
Financial Integrity. Describe the methods that are employed to ensure the integrity of payments that have
been made for waiver services, including: (a) requirements concerning the independent audit of provider
agencies; (b) the financial audit program that the state conducts to ensure the integrity of provider billings
for Medicaid payment of waiver services, including the methods, scope and frequency of audits; and, (c)
the agency (or agencies) responsible for conducting the financial audit program. State laws, regulations,
and policies referenced in the description are available to CMS upon request through the Medicaid agency
or the operating agency (if applicable).

Quality Improvement: Financial Accountability
As a distinct component of the State’s quality improvement strategy, provide information
in the following fields to detail the State’s methods for discovery and remediation.
a.

Methods for Discovery: Financial Accountability Assurance
The State must demonstrate that it has designed and implemented an adequate system
for ensuring financial accountability of the waiver program. (For waiver actions
submitted before June 1, 2014, this assurance read “State financial oversight exists to
assure that claims are coded and paid for in accordance with the reimbursement
methodology specified in the approved waiver.”)

i. Sub-assurances:
a Sub-assurance: The State provides evidence that claims are coded and paid for in
accordance with the reimbursement methodology specified in the approved waiver and
only for services rendered. (Performance measures in this sub-assurance include all
Appendix I performance measures for waiver actions submitted before June 1, 2014.)
a.i. Performance Measures
State:
Effective Date

Appendix I-1: 1

Appendix I: Financial Accountability
HCBS Waiver Application Version 3.5

For each performance measure the State will use to assess compliance with the
statutory assurance complete the following. Where possible, include
numerator/denominator.
For each performance measure, provide information on the aggregated data that will
enable the State to analyze and assess progress toward the performance measure. In this
section provide information on the method by which each source of data is analyzed
statistically/deductively or inductively, how themes are identified or conclusions drawn,
and how recommendations are formulated, where appropriate.
Performance
Measure:
Data Source (Select one) (Several options are listed in the on-line application):
If ‘Other’ is selected, specify:
Responsible Party for
data
collection/generation
(check each that
applies)

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

 State Medicaid

 Weekly

 100% Review

Agency
 Operating Agency

 Monthly

 Less than 100%

 Sub-State Entity

 Quarterly

 Other

 Annually

Review
 Representative
Sample; Confidence
Interval =

Specify:

 Continuously and

 Stratified:

Ongoing
 Other
Specify:

Describe Group:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies
 State Medicaid Agency
 Operating Agency
 Sub-State Entity

(check each that
applies
 Weekly
 Monthly
 Quarterly

State:
Effective Date

Appendix I-1: 2

Appendix I: Financial Accountability
HCBS Waiver Application Version 3.5

 Other

 Annually

Specify:

 Continuously and
Ongoing

 Other
Specify:

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

Sub-assurance: The State provides evidence that rates remain consistent with the
approved rate methodology throughout the five year waiver cycle.
For each performance measure the State will use to assess compliance with the
statutory assurance (or sub-assurance), complete the following. Where possible,
include numerator/denominator.
For each performance measure, provide information on the aggregated data that will
enable the State to analyze and assess progress toward the performance measure. In this
section provide information on the method by which each source of data is analyzed
statistically/deductively or inductively, how themes are identified or conclusions drawn,
and how recommendations are formulated, where appropriate.

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

 State Medicaid

 Weekly

 100% Review

Agency
 Operating Agency

 Monthly

 Less than 100%

 Sub-State Entity

 Quarterly

 Other

 Annually

Review
 Representative
Sample; Confidence
Interval =

Specify:

State:
Effective Date

Appendix I-1: 3

Appendix I: Financial Accountability
HCBS Waiver Application Version 3.5

 Continuously and

 Stratified:

Ongoing
 Other
Specify:

Describe Group:

 Other Specify:

Add another Data Source for this performance measure
Data Aggregation and Analysis
Responsible Party for
data aggregation and
analysis

Frequency of data
aggregation and
analysis:

(check each that
applies
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other

(check each that
applies
 Weekly
 Monthly
 Quarterly
 Annually

Specify:

 Continuously and
Ongoing
 Other
Specify:

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

ii.

Methods for Remediation/Fixing Individual Problems

State:
Effective Date

Appendix I-1: 4

Appendix I: Financial Accountability
HCBS Waiver Application Version 3.5

ii.

Remediation Data Aggregation

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

Responsible Party (check

each that applies)

Frequency of data
aggregation and
analysis:

(check each that
applies)
 State Medicaid Agency
 Operating Agency
 Sub-State Entity
 Other
Specify:

 Weekly
 Monthly
 Quarterly
 Annually
 Continuously and
Ongoing
 Other
Specify:

Timelines

When the State does not have all elements of the Quality Improvement Strategy in place,

provide timelines to design methods for discovery and remediation related to the

assurance of Financial Accountability that are currently non-operational.



Yes

Please provide a detailed strategy for assuring Financial Accountability, the specific
timeline for implementing identified strategies, and the parties responsible for its
operation.

State:
Effective Date

Appendix I-1: 5

APPENDIX I-2: Rates, Billing and Claims
a. Rate Determination Methods. In two pages or less, describe the methods that are employed to
establish provider payment rates for waiver services and the entity or entities that are responsible for
rate determination. Indicate any opportunity for public comment in the process. If different methods
are employed for various types of services, the description may group services for which the same
method is employed. State laws, regulations, and policies referenced in the description are available
upon request to CMS through the Medicaid agency or the operating agency (if applicable).

b. Flow of Billings. Describe the flow of billings for waiver services, specifying whether provider
billings flow directly from providers to the State’s claims payment system or whether billings are
routed through other intermediary entities. If billings flow through other intermediary entities, specify
the entities:

c. Certifying Public Expenditures (select one):
 No. State or local government agencies do not certify expenditures for waiver services.
 Yes. State or local government agencies directly expend funds for part or all of the cost of
waiver services and certify their State government expenditures (CPE) in lieu of billing
that amount to Medicaid.
Select at least one:


Certified Public Expenditures (CPE) of State Public Agencies.
Specify: (a) the State government agency or agencies that certify public expenditures for
waiver services; (b) how it is assured that the CPE is based on the total computable costs
for waiver services; and, (c) how the State verifies that the certified public expenditures
are eligible for Federal financial participation in accordance with 42 CFR §433.51(b).
(Indicate source of revenue for CPEs in Item I-4-a.)



Certified Public Expenditures (CPE) of Local Government Agencies.
Specify: (a) the local government agencies that incur certified public expenditures for
waiver services; (b) how it is assured that the CPE is based on total computable costs for
waiver services; and, (c) how the State verifies that the certified public expenditures are
eligible for Federal financial participation in accordance with 42 CFR §433.51(b).
(Indicate source of revenue for CPEs in Item I-4-b.)

State:
Effective Date

Appendix I-2: 1

d. Billing Validation Process. Describe the process for validating provider billings to produce the claim
for federal financial participation, including the mechanism(s) to assure that all claims for payment are
made only: (a) when the individual was eligible for Medicaid waiver payment on the date of service;
(b) when the service was included in the participant’s approved service plan; and, (c) the services were
provided:

e. Billing and Claims Record Maintenance Requirement. Records documenting the audit trail of
adjudicated claims (including supporting documentation) are maintained by the Medicaid agency, the
operating agency (if applicable), and providers of waiver services for a minimum period of 3 years as
required in 45 CFR § 92.42.

State:
Effective Date

Appendix I-2: 2

APPENDIX I-3: Payment
a.

Method of payments — MMIS (select one):


Payments for all waiver services are made through an approved Medicaid Management
Information System (MMIS).



Payments for some, but not all, waiver services are made through an approved MMIS.
Specify: (a) the waiver services that are not paid through an approved MMIS; (b) the process
for making such payments and the entity that processes payments; (c) how an audit trail is
maintained for all state and federal funds expended outside the MMIS; and, (d) the basis for
the draw of federal funds and claiming of these expenditures on the CMS-64.



Payments for waiver services are not made through an approved MMIS.
Specify: (a) the process by which payments are made and the entity that processes payments;
(b) how and through which system(s) the payments are processed; (c) how an audit trail is
maintained for all state and federal funds expended outside the MMIS; and, (d) the basis for
the draw of federal funds and claiming of these expenditures on the CMS-64:



Payments for waiver services are made by a managed care entity or entities. The
managed care entity is paid a monthly capitated payment per eligible enrollee through
an approved MMIS.
Describe how payments are made to the managed care entity or entities:

b. Direct payment. In addition to providing that the Medicaid agency makes payments directly to
providers of waiver services, payments for waiver services are made utilizing one or more of the
following arrangements (select at least one):


The Medicaid agency makes payments directly and does not use a fiscal agent
(comprehensive or limited) or a managed care entity or entities.



The Medicaid agency pays providers through the same fiscal agent used for the rest of
the Medicaid program.



The Medicaid agency pays providers of some or all waiver services through the use of
a limited fiscal agent.
Specify the limited fiscal agent, the waiver services for which the limited fiscal agent makes
payment, the functions that the limited fiscal agent performs in paying waiver claims, and
the methods by which the Medicaid agency oversees the operations of the limited fiscal
agent:



Providers are paid by a managed care entity or entities for services that are included in
the State’s contract with the entity.
Specify how providers are paid for the services (if any) not included in the State’s contract
with managed care entities.

State:
Effective Date

Appendix I-3: 1

Supplemental or Enhanced Payments. Section 1902(a)(30) requires that payments for services be
consistent with efficiency, economy, and quality of care. Section 1903(a)(1) provides for Federal
financial participation to States for expenditures for services under an approved State plan/waiver.
Specify whether supplemental or enhanced payments are made. Select one:


No. The State does not make supplemental or enhanced payments for waiver services.



Yes. The State makes supplemental or enhanced payments for waiver services.
Describe: (a) the nature of the supplemental or enhanced payments that are made and the
waiver services for which these payments are made; (b) the types of providers to which such
payments are made; (c) the source of the non-Federal share of the supplemental or enhanced
payment; and, (d) whether providers eligible to receive the supplemental or enhanced
payment retain 100% of the total computable expenditure claimed by the State to CMS.
Upon request, the State will furnish CMS with detailed information about the total amount
of supplemental or enhanced payments to each provider type in the waiver.

Payments to State or Local Government Providers. Specify whether State or local government
providers receive payment for the provision of waiver services.


No. State or local government providers do not receive payment for waiver services.
Do notcomplete Item I-3-e.



Yes. State or local government providers receive payment for waiver services.
Complete item I-3-e.
Specify the types of State or local government providers that receive payment for waiver
services and the services that the State or local government providers furnish. Complete item
I-3-e.

Amount of Payment to State or Local Government Providers.
Specify whether any State or local government provider receives payments (including regular and any
supplemental payments) that in the aggregate exceed its reasonable costs of providing waiver services
and, if so, whether and how the State recoups the excess and returns the Federal share of the excess to
CMS on the quarterly expenditure report. Select one:


The amount paid to State or local government providers is the same as the amount paid
to private providers of the same service.



The amount paid to State or local government providers differs from the amount paid
to private providers of the same service. No public provider receives payments that in
the aggregate exceed its reasonable costs of providing waiver services.

State:
Effective Date

Appendix I-3: 2



The amount paid to State or local government providers differs from the amount paid
to private providers of the same service. When a State or local government provider
receives payments (including regular and any supplemental payments) that in the
aggregate exceed the cost of waiver services, the State recoups the excess and returns
the federal share of the excess to CMS on the quarterly expenditure report.
Describe the recoupment process:

Provider Retention of Payments. Section 1903(a)(1) provides that Federal matching funds are only
available for expenditures made by states for services under the approved waiver. Select one:


Providers receive and retain 100 percent of the amount claimed to CMS for waiver
services.



Providers are paid by a managed care entity (or entities) that is paid a monthly
capitated payment.
Specify whether the monthly capitated payment to managed care entities is reduced or
returned in part to the State.

Additional Payment Arrangements
i.

ii.

Voluntary Reassignment of Payments to a Governmental Agency. Select one:


No. The State does not provide that providers may voluntarily reassign their right
to direct payments to a governmental agency.



Yes. Providers may voluntarily reassign their right to direct payments to a
governmental agency as provided in 42 CFR §447.10(e).
Specify the governmental agency (or agencies) to which reassignment may be made.

Organized Health Care Delivery System. Select one:

State:
Effective Date



No. The State does not employ Organized Health Care Delivery System (OHCDS)
arrangements under the provisions of 42 CFR §447.10.



Yes. The waiver provides for the use of Organized Health Care Delivery System
arrangements under the provisions of 42 CFR §447.10.
Specify the following: (a) the entities that are designated as an OHCDS and how these
entities qualify for designation as an OHCDS; (b) the procedures for direct provider
enrollment when a provider does not voluntarily agree to contract with a designated
OHCDS; (c) the method(s) for assuring that participants have free choice of qualified
providers when an OHCDS arrangement is employed, including the selection of
providers not affiliated with the OHCDS; (d) the method(s) for assuring that providers
that furnish services under contract with an OHCDS meet applicable provider
qualifications under the waiver; (e) how it is assured that OHCDS contracts with
providers meet applicable requirements; and, (f) how financial accountability is assured
when an OHCDS arrangement is used:

Appendix I-3: 3

iii. Contracts with MCOs, PIHPs or PAHPs. Select one:

State:
Effective Date



The State does not contract with MCOs, PIHPs or PAHPs for the provision of
waiver services.



The State contracts with a Managed Care Organization(s) (MCOs) and/or prepaid
inpatient health plan(s) (PIHP) or prepaid ambulatory health plan(s) (PAHP)
under the provisions of §1915(a)(1) of the Act for the delivery of waiver and other
services. Participants may voluntarily elect to receive waiver and other services
through such MCOs or prepaid health plans. Contracts with these health plans
are on file at the State Medicaid agency.
Describe: (a) the MCOs and/or health plans that furnish services under the provisions
of §1915(a)(1); (b) the geographic areas served by these plans; (c) the waiver and other
services furnished by these plans; and (d) how payments are made to the health plans.



This waiver is a part of a concurrent §1915(b)/§1915(c) waiver. Participants are
required to obtain waiver and other services through a MCO and/or prepaid
inpatient health plan (PIHP) or a prepaid ambulatory health plan (PAHP). The
§1915(b) waiver specifies the types of health plans that are used and how payments
to these plans are made.

Appendix I-3: 4

APPENDIX I-4: Non-Federal Matching Funds
a.

State Level Source(s) of the Non-Federal Share of Computable Waiver Costs. Specify the State
source or sources of the non-federal share of computable waiver costs. Select at least one:


Appropriation of State Tax Revenues to the State Medicaid agency



Appropriation of State Tax Revenues to a State Agency other than the Medicaid Agency.
If the source of the non-federal share is appropriations to another state agency (or agencies),
specify: (a) the State entity or agency receiving appropriated funds and (b) the mechanism that
is used to transfer the funds to the Medicaid Agency or Fiscal Agent, such as an
Intergovernmental Transfer (IGT), including any matching arrangement, and/or, indicate if the
funds are directly expended by State agencies as CPEs, as indicated in Item I-2-c:



Other State Level Source(s) of Funds.
Specify: (a) the source and nature of funds; (b) the entity or agency that receives the funds; and
(c) the mechanism that is used to transfer the funds to the Medicaid Agency or Fiscal Agent,
such as an Intergovernmental Transfer (IGT), including any matching arrangement, and/or,
indicate if funds are directly expended by State agencies as CPEs, as indicated in Item I-2-c:

Local Government or Other Source(s) of the Non-Federal Share of Computable Waiver Costs.
Specify the source or sources of the non-federal share of computable waiver costs that are not from state
sources. Select one:



Not Applicable. There are no local government level sources of funds utilized as the nonfederal share.



Applicable
Check each that applies:

State:
Effective Date



Appropriation of Local Government Revenues.
Specify: (a) the local government entity or entities that have the authority to levy taxes or
other revenues; (b) the source(s) of revenue; and, (c) the mechanism that is used to transfer
the funds to the Medicaid Agency or Fiscal Agent, such as an Intergovernmental Transfer
(IGT), including any matching arrangement (indicate any intervening entities in the
transfer process), and/or, indicate if funds are directly expended by local government
agencies as CPEs, as specified in Item I-2-c:



Other Local Government Level Source(s) of Funds.
Specify: (a) the source of funds; (b) the local government entity or agency receiving funds;
and, (c) the mechanism that is used to transfer the funds to the State Medicaid Agency or
Fiscal Agent, such as an Intergovernmental Transfer (IGT), including any matching
arrangement, and /or, indicate if funds are directly expended by local government agencies
as CPEs, as specified in Item I-2- c:

Appendix I-4: 1

Information Concerning Certain Sources of Funds. Indicate whether any of the funds listed in Items
I-4-a or I-4-b that make up the non-federal share of computable waiver costs come from the following
sources: (a) health care-related taxes or fees; (b) provider-related donations; and/or, (c) federal funds .
Select one:


None of the specified sources of funds contribute to the non-federal share of computable
waiver costs.



The following source(s) are used.
Check each that applies.


Health care-related taxes or fees



Provider-related donations



Federal funds

For each source of funds indicated above, describe the source of the funds in detail:

State:
Effective Date

Appendix I-4: 2

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

Services Furnished in Residential Settings. Select one:


No services under this waiver are furnished in residential settings other than the private
residence of the individual.



As specified in Appendix C, the State furnishes waiver services in residential settings
other than the personal home of the individual.

b. Method for Excluding the Cost of Room and Board Furnished in Residential Settings. The
following describes the methodology that the State uses to exclude Medicaid payment for room and
board in residential settings:

State:
Effective Date

Appendix I-5: 1

APPENDIX I-6: Payment for Rent and Food Expenses
of an Unrelated Live-In Caregiver
Reimbursement for the Rent and Food Expenses of an Unrelated Live-In Personal Caregiver.
Select one:


No. The State does not reimburse for the rent and food expenses of an unrelated live-in personal
caregiver who resides in the same household as the participant.



Yes. Per 42 CFR §441.310(a)(2)(ii), the State will claim FFP for the additional costs of rent and
food that can be reasonably attributed to an unrelated live-in personal caregiver who resides
in the same household as the waiver participant. The State describes its coverage of live-in
caregiver in Appendix C-3 and the costs attributable to rent and food for the live-in caregiver
are reflected separately in the computation of factor D (cost of waiver services) in Appendix J.
FFP for rent and food for a live-in caregiver will not be claimed when the participant lives in
the caregiver’s home or in a residence that is owned or leased by the provider of Medicaid
services.
The following is an explanation of: (a) the method used to apportion the additional costs of rent and
food attributable to the unrelated live-in personal caregiver that are incurred by the individual served
on the waiver and (b) the method used to reimburse these costs:

State:
Effective Date

Appendix I-6: 1

APPENDIX I-7: Participant Co-Payments for Waiver Services
and Other Cost Sharing
a. Co-Payment Requirements. Specify whether the State imposes a co-payment or similar charge upon
waiver participants for waiver services. These charges are calculated per service and have the effect of
reducing the total computable claim for federal financial participation. Select one:


No. The State does not impose a co-payment or similar charge upon participants for
waiver services. (Do not complete the remaining items; proceed to Item I-7-b).



Yes. The State imposes a co-payment or similar charge upon participants for one or more
waiver services. (Complete the remaining items)

Co-Pay Arrangement
Specify the types of co-pay arrangements that are imposed on waiver participants (check each
that applies):
Charges Associated with the Provision of Waiver Services (if any are checked, complete Items
I-7-a-ii through I-7-a-iv):


Nominal deductible



Coinsurance



Co-Payment



Other charge
Specify:

ii Participants Subject to Co-pay Charges for Waiver Services.
Specify the groups of waiver participants who are subject to charges for the waiver services specified
in Item I-7-a-iii and the groups for whom such charges are excluded

iii. Amount of Co-Pay Charges for Waiver Services. The following table lists the waiver services
defined in C-1/C-3 for which a charge is made, the amount of the charge, and the basis for
determining the charge.
Waiver Service

Charge
Amount

State:
Effective Date

Basis

Appendix I-7: 1

iv. Cumulative Maximum Charges.
Indicate whether there is a cumulative maximum amount for all co-payment charges to a waiver
participant (select one):



There is no cumulative maximum for all deductible, coinsurance or co-payment
charges to a waiver participant.



There is a cumulative maximum for all deductible, coinsurance or co-payment
charges to a waiver participant.
Specify the cumulative maximum and the time period to which the maximum applies:

Other State Requirement for Cost Sharing. Specify whether the State imposes a premium, enrollment
fee or similar cost sharing on waiver participants. Select one:


No. The State does not impose a premium, enrollment fee, or similar cost-sharing
arrangement on waiver participants.



Yes. The State imposes a premium, enrollment fee or similar cost-sharing arrangement.
Describe in detail the cost sharing arrangement, including: (a) the type of cost sharing (e.g.,
premium, enrollment fee); (b) the amount of charge and how the amount of the charge is related
to total gross family income (c) the groups of participants subject to cost-sharing and the groups
who are excluded; and (d) the mechanisms for the collection of cost-sharing and reporting the
amount collected on the CMS 64:

State:
Effective Date

Appendix I-7: 2

Appendix J: Cost Neutrality Demonstration
HCBS Waiver Application Version 3.5

Appendix J: Cost Neutrality Demonstration
Appendix J-1: Composite Overview and Demonstration
of Cost-Neutrality Formula
Composite Overview. Complete the fields in Cols. 3, 5 and 6 in the following table for each waiver
year. The fields in Cols. 4, 7 and 8 are auto-calculated based on entries in Cols 3, 5, and 6. The
fields in Col. 2 are auto-calculated using the Factor D data from the J-2d Estimate of Factor D
tables. Col. 2 fields will be populated ONLY when the Estimate of Factor D tables in J-2d have
been completed.

Level(s) of Care (specify):
Col. 1

Year

Col. 2

Factor D

Col. 3

Col. 4

Factor D′

Total:
D+D′

Col. 5

Factor G

Col. 6

Col. 7

Col. 8

Factor G′

Total:
G+G′

Difference
(Column 7 less
Column 4)

1
2
3
4
5

State:
Effective Date

Appendix J-1: 1

Appendix J-2: Derivation of Estimates
a. Number Of Unduplicated Participants Served. Enter the total number of unduplicated participants
from Item B-3-a who will be served each year that the waiver is in operation. When the waiver serves
individuals under more than one level of care, specify the number of unduplicated participants for each
level of care:
Table J-2-a: Unduplicated Participants

Waiver Year

Total Unduplicated Number
of Participants
(from Item B-3-a)

Distribution of Unduplicated Participants by
Level of Care (if applicable)
Level of Care:

Level of Care:

Year 1
Year 2
Year 3
Year 4 (only appears if
applicable based on
Item 1-C)
Year 5 (only appears if
applicable based on
Item 1-C)
b.

Average Length of Stay. Describe the basis of the estimate of the average length of stay on the waiver
by participants in Item J-2-a.

Derivation of Estimates for Each Factor. Provide a narrative description for the derivation of the
estimates of the following factors.
i.

Factor D Derivation. The estimates of Factor D for each waiver year are located in Item J-2-d.
The basis for these estimates is as follows:

ii.

Factor D′ Derivation. The estimates of Factor D’ for each waiver year are included in
Item J-1. The basis of these estimates is as follows:

State:
Effective Date

Appendix J-2: 1

iii.

Factor G Derivation. The estimates of Factor G for each waiver year are included in Item J-1.
The basis of these estimates is as follows:

iv.

Factor G′ Derivation. The estimates of Factor G’ for each waiver year are included in Item J-1.
The basis of these estimates is as follows:

Component management for waiver services. If the service(s) below includes two or more discrete
services that are reimbursed separately, or is a bundled service, each component of the service must be listed.
Select “manage components” to add these components.
Waiver Services
manage components
manage components
manage components
manage components
manage components
manage components

State:
Effective Date

Appendix J-2: 2

Estimate of Factor D. Select one: Note: Selection below is new.


The waiver does not operate concurrently with a §1915(b) waiver. Complete Item J-2-d-i



The waiver operates concurrently with a §1915(b) waiver. Complete Item J-2-d-ii

Estimate of Factor D – Non-Concurrent Waiver. Complete the following table for each waiver year.
Enter data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fields for all the Waiver
Service/Component items. Select Save and Calculate to automatically calculate and populate the
Component Costs and Total Costs fields. All fields in this table must be completed in order to populate
the Factor D fields in the J-1 Composite Overview table.
Waiver Year: Year 1

Waiver Service / Component

Col. 1

Col. 2

Col. 3

Col. 4

Col. 5

Unit

# Users

Avg. Units
Per User

Avg. Cost/
Unit

Total Cost

GRAND TOTAL:
TOTAL ESTIMATED UNDUPLICATED PARTICIPANTS (from Table J-2-a)
FACTOR D (Divide grand total by number of participants)
AVERAGE LENGTH OF STAY ON THE WAIVER

State:
Effective Date

Appendix J-2: 3

Waiver Year: Year 2
Waiver Service / Component

Col. 1

Col. 2

Col. 3

Col. 4

Col. 5

Unit

# Users

Avg. Units
Per User

Avg. Cost/
Unit

Total Cost

GRAND TOTAL:
TOTAL ESTIMATED UNDUPLICATED PARTICIPANTS (from Table J-2-a)
FACTOR D (Divide grand total by number of participants)
AVERAGE LENGTH OF STAY ON THE WAIVER

State:
Effective Date

Appendix J-2: 4

Waiver Year: Year 3
Waiver Service / Component

Col. 1

Col. 2

Col. 3

Col. 4

Col. 5

Unit

# Users

Avg. Units
Per User

Avg. Cost/
Unit

Total Cost

GRAND TOTAL:
TOTAL ESTIMATED UNDUPLICATED PARTICIPANTS (from Table J-2-a)
FACTOR D (Divide grand total by number of participants)
AVERAGE LENGTH OF STAY ON THE WAIVER

State:
Effective Date

Appendix J-2: 5

Waiver Year: Year 4 (only appears if applicable based on Item 1-C)
Waiver Service / Component

Col. 1

Col. 2

Col. 3

Col. 4

Col. 5

Unit

# Users

Avg. Units
Per User

Avg. Cost/
Unit

Total Cost

GRAND TOTAL:
TOTAL ESTIMATED UNDUPLICATED PARTICIPANTS (from Table J-2-a)
FACTOR D (Divide grand total by number of participants)
AVERAGE LENGTH OF STAY ON THE WAIVER

State:
Effective Date

Appendix J-2: 6

Waiver Year: Year 5 (only appears if applicable based on Item 1-C)
Waiver Service / Component

Col. 1

Col. 2

Col. 3

Col. 4

Col. 5

Unit

# Users

Avg. Units
Per User

Avg. Cost/
Unit

Total Cost

GRAND TOTAL:
TOTAL ESTIMATED UNDUPLICATED PARTICIPANTS (from Table J-2-a)
FACTOR D (Divide grand total by number of participants)
AVERAGE LENGTH OF STAY ON THE WAIVER

State:
Effective Date

Appendix J-2: 7

ii.

Estimate of Factor D – Concurrent §1915(b)/§1915(c) Waivers, or other authorities utilizing
capitated arrangements (i.e., 1915(a), 1932(a), Section 1937). Complete the following table for each
waiver year. Enter data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fields for all the
Waiver Service/Component items. If applicable, check the capitation box next to that service. Select
Save and Calculate to automatically calculate and populate the Component Costs and Total Costs fields.
All fields in this table must be completed in order to populate the Factor D fields in the J-1 Composite
Overview table.
Waiver Year: Year 1

Waiver Service /
Component

Col. 1

Col. 2

Col. 3

Col. 4

Col. 5

Col. 6

Check if
included in
capitation

Unit

# Users

Avg. Units
Per User

Avg. Cost/
Unit

Total Cost


















GRAND TOTAL:
Total: Services included in capitation
Total: Services not included in capitation
TOTAL ESTIMATED UNDUPLICATED PARTICIPANTS (from Table J-2-a)
FACTOR D (Divide grand total by number of participants)
Services included in capitation
Services not included in capitation
AVERAGE LENGTH OF STAY ON THE WAIVER

State:
Effective Date

Appendix J-2: 8

Waiver Year: Year 2
Waiver Service /
Component

Col. 1

Col. 2

Col. 3

Col. 4

Col. 5

Col. 6

Check if
included in
capitation

Unit

# Users

Avg. Units
Per User

Avg. Cost/
Unit

Total Cost

State:
Effective Date

Appendix J-2: 9

Waiver Year: Year 3
Waiver Service /
Component

Col. 1

Col. 2

Col. 3

Col. 4

Col. 5

Col. 6

Check if
included in
capitation

Unit

# Users

Avg. Units
Per User

Avg. Cost/
Unit

Total Cost

State:
Effective Date

Appendix J-2: 10

Waiver Year: Year 4 (only appears if applicable based on Item 1-C)
Waiver Service /
Component

Col. 1

Col. 2

Col. 3

Col. 4

Col. 5

Col. 6

Check if
included in
capitation

Unit

# Users

Avg. Units
Per User

Avg. Cost/
Unit

Total Cost

State:
Effective Date

Appendix J-2: 11

Waiver Year: Year 5 (only appears if applicable based on Item 1-C)
Waiver Service /
Component

Col. 1

Col. 2

Col. 3

Col. 4

Col. 5

Col. 6

Check if
included in
capitation

Unit

# Users

Avg. Units
Per User

Avg. Cost/
Unit

Total Cost

State:
Effective Date

Appendix J-2: 12

File Type	application/pdf
File Title	Application for a §1915 (c) HCBS Waiver
File Modified	2017-03-01
File Created	2016-10-25