PURPOSE OF THE HCBS WAIVER PROGRAM

1. Major Changes

1. Request Information (1 of 3)

1. The State of Utah requests approval for a Medicaid home and community-based services (HCBS) waiver under the authority of §1915(c) of the Social Security Act (the Act).
2. Program Title (optional - this title will be used to locate this waiver in the finder):

   Medicaid Autism Waiver
3. Type of Request: 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

   Waiver Number:UT.1029.R01.00
   Draft ID:UT.024.01.00
4. Type of Waiver (select only one):
   Model Waiver Regular Waiver
5. Proposed Effective Date: (mm/dd/yy)
   Approved Effective Date: 10/01/15

1. Request Information (2 of 3)

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

    Hospital as defined in 42 CFR §440.10

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

   Character Count: out of 6000

    Inpatient psychiatric facility for individuals age 21 and under as provided in42 CFR §440.160

    not selected
   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:

   Character Count: out of 6000

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

    not selected
   Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) (as defined in 42 CFR §440.150)
   If applicable, specify whether the State additionally limits the waiver to subcategories of the ICF/IID level of care:

   Character Count: out of 6000

   The State limits the waiver to children ages two through six years who have a confirmed autism spectrum disorder diagnosis. Diagnosis must be rendered by a clinician who is authorized under the scope of their licensure.

1. Request Information (3 of 3)

7. 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:

   Character Count: out of 6000

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

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

   §1915(b)(2) (central broker)

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

   §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:

   Character Count: out of 6000

   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:

   Character Count: out of 6000

   Not applicable
    not selected
8. Dual Eligiblity for Medicaid and Medicare.
   Check if applicable:
   This waiver provides services for individuals who are eligible for both Medicare and Medicaid.

2. Brief Waiver Description

3. Components of the Waiver Request

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

1. Waiver Administration and Operation. Appendix A specifies the administrative and operational structure of this waiver.

2. 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.

3. Participant Services. Appendix C specifies the home and community-based waiver services that are furnished through the waiver, including applicable limitations on such services.

4. 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).

5. 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.

    not selected

6. 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.

7. Participant Safeguards. Appendix G describes the safeguards that the State has established to assure the health and welfare of waiver participants in specified areas.

8. Quality Improvement Strategy. Appendix H contains the Quality Improvement Strategy for this waiver.

9. 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.

10. Cost-Neutrality Demonstration. Appendix J contains the State's demonstration that the waiver is cost-neutral.

4. Waiver(s) Requested

1. 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.
2. 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

    not selected
3. Statewideness. Indicate whether the State requests a waiver of the statewideness requirements in §1902(a)(1) of the Act (select one):

   No

   Yes

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

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

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

   Character Count: out of 6000

   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:

   Character Count: out of 6000

5. Assurances

1. 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.

2. 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.

3. 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.

4. Choice of Alternatives: The State assures that when an individual is determined to be likely to require the level of care specified for this waiver and is in a target group specified in Appendix B, the individual (or, legal representative, if applicable) is:

   1. Informed of any feasible alternatives under the waiver; and,

   2. Given the choice of either institutional or home and community-based waiver services. Appendix B specifies the procedures that the State employs to ensure that individuals are informed of feasible alternatives under the waiver and given the choice of institutional or home and community-based waiver services.

5. 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.

6. 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.

7. 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.

8. 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.

9. Habilitation Services. The State assures that prevocational, educational, or supported employment services, or a combination of these services, if provided as habilitation services under the waiver are: (1) not otherwise available to the individual through a local educational agency under the Individuals with Disabilities Education Act (IDEA) or the Rehabilitation Act of 1973; and, (2) furnished as part of expanded habilitation services.

10. Services for Individuals with Chronic Mental Illness. The State assures that federal financial participation (FFP) will not be claimed in expenditures for waiver services including, but not limited to, day treatment or partial hospitalization, psychosocial rehabilitation services, and clinic services provided as home and community-based services to individuals with chronic mental illnesses if these individuals, in the absence of a waiver, would be placed in an IMD and are: (1) age 22 to 64; (2) age 65 and older and the State has not included the optional Medicaid benefit cited in 42 CFR §440.140; or (3) age 21 and under and the State has not included the optional Medicaid benefit cited in 42 CFR § 440.160.

6. Additional Requirements

1. 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.

2. 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.

3. 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.

4. Access to Services. The State does not limit or restrict participant access to waiver services except as provided in Appendix C.

5. 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.

6. 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 non-Medicaid), 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.

7. 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.

8. Quality Improvement. The State operates a formal, comprehensive system to ensure that the waiver meets the assurances and other requirements contained in this application. Through an ongoing process of discovery, remediation and improvement, the State assures the health and welfare of participants by monitoring: (a) level of care determinations; (b) individual plans and services delivery; (c) provider qualifications; (d) participant health and welfare; (e) financial oversight and (f) administrative oversight of the waiver. The State further assures that all problems identified through its discovery processes are addressed in an appropriate and timely manner, consistent with the severity and nature of the problem. During the period that the waiver is in effect, the State will implement the Quality Improvement Strategy specified in Appendix H.

9. Public Input. Describe how the State secures public input into the development of the waiver:
   Character Count: out of 6000
   From May 22nd, 2015 through June 22nd, 2015, a copy of the draft State Implementation Plan was posted online at http://health.utah.gov/ltc. Public comment was accepted by mail, fax and online submission. In addition, on May 8th, the State presented information on the waiver renewal to the Utah Indian Health Advisory Board (UIHAB) which represents all federally recognized Tribal Governments within the State and on May 18th, a summary of the changes was supplied to the Medical Care Advisory Committee (MCAC). On May 22nd, 2015, information on the renewal was published in the newspaper with instructions on how a copy of the implementation plan could be requested and how comment may be submitted. Hard copies were also made available at the Department of Health as well as Department of Human Services buildings. The State did not receive any comments on this renewal.

10. 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 is provided by Presidential Executive Order 13175 of November 6, 2000. Evidence of the applicable notice is available through the Medicaid Agency.

11. Limited English Proficient Persons. The State assures that it provides meaningful access to waiver services by Limited English Proficient persons in accordance with: (a) Presidential Executive Order 13166 of August 11, 2000 (65 FR 50121) and (b) Department of Health and Human Services "Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons" (68 FR 47311 - August 8, 2003). Appendix B describes how the State assures meaningful access to waiver services by Limited English Proficient persons.

7. Contact Person(s)

1. The Medicaid agency representative with whom CMS should communicate regarding the waiver is:
   Last Name:

   First Name:

   Title:

   Agency:

   Address:

   Address 2:

   City:

   State:

   Utah

   Zip:

   Phone:

   Ext: TTY

   Fax:

   E-mail:

2. 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:

   Utah

   Zip:

   Phone:

   Ext: TTY

   Fax:

   E-mail:

8. Authorizing Signature

Attachments

Specify the transition plan for the waiver:

Additional Needed Information (Optional)

Appendix A: Waiver Administration and Operation

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

    The waiver is operated by the State Medicaid agency.

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

    The Medical Assistance Unit.

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

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

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

    not selected
    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:The Utah Department of Human Services, Division of Services for People with Disabilities

   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).

    not selected

Appendix A: Waiver Administration and Operation

2. Oversight of Performance.

   1. Medicaid Director Oversight of Performance When the Waiver is Operated by another Division/Unit within the State Medicaid Agency. When the waiver is operated by another division/administration within the umbrella agency designated as the Single State Medicaid Agency. Specify (a) the functions performed by that division/administration (i.e., the Developmental Disabilities Administration within the Single State Medicaid Agency), (b) the document utilized to outline the roles and responsibilities related to waiver operation, and (c) the methods that are employed by the designated State Medicaid Director (in some instances, the head of umbrella agency) in the oversight of these activities:
      As indicated in section 1 of this appendix, the waiver is not operated by another division/unit within the State Medicaid agency. Thus this section does not need to be completed.
      Character Count: out of 12000
   2. 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:
      Character Count: out of 12000
      An interagency agreement between the State Medicaid Agency (SMA) and the Division of Services for People with Disabilities (DSPD) sets forth the respective responsibilities for the administration and operation of this waiver. The agreement delineates the SMA’s overall responsibility to provide management and oversight of the waiver, as well as DSPD’s operational and administrative functions. The responsibilities of the operating agency are delegated as follows. All of these responsibilities are shared to some extent with the SMA: 1. Program Development 2. Rate Setting and Fiscal Accountability 3. Program Coordination, Education and Outreach 4. HCBS Waiver Staffing Assurances 5. Eligibility Determination and Waiver Participation Assurances 6. Waiver Participant Involvement in Decision Making 7. Hearings and Appeals 8. Monitoring, Quality Management and Quality Improvement 9. Reporting 10. Data Security The SMA monitors the interagency agreement through a series of quality assurance activities, provides ongoing technical assistance, and reviews and approves all rules, regulations and policies that govern waiver operations. Formal program reviews are conducted at regularly scheduled intervals by the Quality Assurance Team. If ongoing reviews conducted by the Quality Assurance Team reveal concerns with compliance DSPD is required to develop plans of correction within specific time frames to correct the problems. The Quality Assurance Team conducts follow up activities to ensure that corrections are sustaining.

Appendix A: Waiver Administration and Operation

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

   Character Count: out of 6000
    No. Contracted entities do not perform waiver operational and administrative functions on behalf of the Medicaid agency and/or the operating agency (if applicable).
    not selected

Appendix A: Waiver Administration and Operation

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

    not selected
    Not applicable
    Applicable - Local/regional non-state agencies perform waiver operational and administrative functions.
   Check each that applies:

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

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

   Character Count: out of 6000

   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:

   Character Count: out of 6000

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

Appendix A: Waiver Administration and Operation

5. Responsibility for Assessment of Performance of Contracted and/or Local/Regional Non-State Entities. Specify the state agency or agencies responsible for assessing the performance of contracted and/or local/regional non-state entities in conducting waiver operational and administrative functions:
   Character Count: out of 6000

Appendix A: Waiver Administration and Operation

6. Assessment Methods and Frequency. Describe the methods that are used to assess the performance of contracted and/or local/regional non-state entities to ensure that they perform assigned waiver operational and administrative functions in accordance with waiver requirements. Also specify how frequently the performance of contracted and/or local/regional non-state entities is assessed:
   Character Count: out of 12000

Appendix A: Waiver Administration and Operation

7. Distribution of Waiver Operational and Administrative Functions. In the following table, specify the entity or entities that have responsibility for conducting each of the waiver operational and administrative functions listed (check each that applies):
   In accordance with 42 CFR §431.10, when the Medicaid agency does not directly conduct a function, it supervises the performance of the function and establishes and/or approves policies that affect the function. All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. Note: More than one box may be checked per item. Ensure that Medicaid is checked when the Single State Medicaid Agency (1) conducts the function directly; (2) supervises the delegated function; and/or (3) establishes and/or approves policies related to the function.

   Function	Medicaid Agency	Other State Operating Agency
   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

Appendix A: Waiver Administration and Operation

Quality Improvement: Administrative Authority of the Single State Medicaid Agency

1. 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.

   1. 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: Number and percentage of DSPD reports specified in the implementation plan that were submitted to the SMA on time and in the correct format. (Numerator= # of DSPD reports in compliance; Denominator=Total # of DSPD reports submitted to the SMA) Data Source (Select one): Other If 'Other' is selected, specify: DSPD Reports/Approval Documents Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percentage of proposed rules and other documents, relating to the implementation of the waiver (including training curriculums and outreach materials) that are submitted by DSPD to the SMA for review and approval prior to implementation. (Numerator=# of documents in compliance; Denominator=Total # of documents) Data Source (Select one): Other If 'Other' is selected, specify: Document Approval Forms/DSPD Documents Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percentage of maximum allowable rates (MARs) for covered waiver services approved by the SMA.(Numerator=# of MARs approved by the SMA; Denominator= total # of MARs) Data Source (Select one): Other If 'Other' is selected, specify: Approval Documents/Correspondance Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: #and% oftimely notice of appeal rights provided to waiver applcnts/partipnts who make one of the following claims:a) denied access to Medicaid Waiver Progrm,b)denied access to needed services while enrolled in the waiver,c)denied choice of provdr when more than one provdr was avbl(Numerator=#of decisions where notice of appeal rights was provdd;Denominator=total decisions requiring appeal rights). Data Source (Select one): Other If 'Other' is selected, specify: Approval Documents/Correspondence Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

   2. 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.
      Character Count: out of 6000
      The SMA demonstrates ultimate administrative authority and responsibility for the operation of the Medicaid Autism Waiver (MAW) program through numerous activities. These include: the issuance of policies, rules, and regulations relating to the waiver; and the approval of all protocols, documents, and trainings, that affect any aspect of MAW operations. Approvals are accomplished through a formal document approval process. The SMA also conducts quarterly meetings with DSPD (the operating agency), monitors compliance with the interagency agreement, conducts annual quality assurance reviews of the MAW program, and provides technical assistance to the operating agency and other entities within the state that affect the operation of the waiver program. An annual review is conducted for each of the five three waiver years. A base line review will be conducted after completion of the first waiver year. The sample size for this review will be sufficient to provide a confidence level equal to 95%, a confidence interval equal to 5 and a response distribution equal to 50%. The response distribution percentage for future reviews will reflect the findings gathered during the base line review. The SMA is the entity responsible for official communication with CMS for all issues related to the MAW.
2. Methods for Remediation/Fixing Individual Problems
   1. 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.
      Character Count: out of 6000
      The SMA has an interagency agreement with the Department of Human Services for the operation and implementation of the waiver as specified in the State Implementation Plan. The interagency agreement requires that DSPD fulfill all requirements stipulated in the implementation plan. When individual issues of non compliance occur the SMA will provide technical assistance including time frames to assure resolution, the results of which will be documented in SMA Reports.
   2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)

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

3. 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.

    No

    Yes

    not selected
   Please provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

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

1. Target Group(s). Under the waiver of Section 1902(a)(10)(B) of the Act, the State limits waiver services to one or more groups or subgroups of individuals. Please see the instruction manual for specifics regarding age limits. In accordance with 42 CFR §441.301(b)(6), select one or more waiver target groups, check each of the subgroups in the selected target group(s) that may receive services under the waiver, and specify the minimum and maximum (if any) age of individuals served in each subgroup:

   Target Group	Included	Target SubGroup	Minimum Age	Maximum Age
   				Maximum Age Limit	No Maximum Age Limit
   Aged or Disabled, or Both - General
   		Aged
   		Disabled (Physical)
   		Disabled (Other)
   Aged or Disabled, or Both - Specific Recognized Subgroups
   		Brain Injury
   		HIV/AIDS
   		Medically Fragile
   		Technology Dependent
   Intellectual Disability or Developmental Disability, or Both
   		Autism
   		Developmental Disability
   		Intellectual Disability
   Mental Illness
   		Mental Illness
   		Serious Emotional Disturbance

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

   Character Count: out of 12000

3. 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:

   Character Count: out of 12000

   At least 90 days prior to the child’s seventh birthday, the support coordinator will work collaboratively with the child’s parents, providers and school officials to establish a plan to transition the child out of home and community based waiver services. During transition planning which is to begin at least 90 days prior to the child’s disenrollment, an overall assessment of the child’s progress will be conducted. If the evaluation demonstrates that the child has ongoing needs that could possibly be met by the Community Supports Waiver (CSW) for Individuals with Intellectual Disabilities, the child will have a standardized Needs Assessment completed. As per R539-2-4 and Utah Code 62A-5-102 (3), DSPD will determine the child's priority relative to others who are seeking access to the CSW. DSPD will use the standardized Needs Assessment to score and prioritize the child's level of need. Persons with the highest scores shall receive support first. If funding is not immediately available, the child would be placed on a waiting list to receive services from DSPD. In addition, the child will be evaluated to determine if they qualify for other community Medicaid programs 90 days prior to the child’s disenrollment.. Additional Autism services may be available under the under the Early and Periodic Screening, Diagnostic, and Treatment program (EPSDT). The child must be under the age of 21 and qualify for traditional Utah Medicaid in order to be considered for this program.

Appendix B: Participant Access and Eligibility

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

1. 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:

   Character Count: out of 6000

    not selected
    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.

   Character Count: out of 6000

   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:

   Character Count: out of 6000

    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.

    not selected

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

   Specify percent:

    Other:

   Specify:

   Character Count: out of 6000

    not selected
    not selected

Appendix B: Participant Access and Eligibility

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

Answers provided in Appendix B-2-a indicate that you do not need to complete this section.

2. 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:
   Character Count: out of 12000
3. 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:

   Character Count: out of 12000
   Other safeguard(s)

   Specify:

   Character Count: out of 12000

Appendix B: Participant Access and Eligibility

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

1. 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
   Year 5

2. 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
   Year 5

Appendix B: Participant Access and Eligibility

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

3. 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).

Appendix B: Participant Access and Eligibility

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

4. 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.

5. 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:

   Character Count: out of 12000
6. Selection of Entrants to the Waiver. Specify the policies that apply to the selection of individuals for entrance to the waiver:
   Character Count: out of 12000
   Please see Utah Administrative Rule R414-509 Autism Waiver Open Enrollment Process which governs the selection of individuals for entrance to the waiver. A brief summary of the rule is as follows: During the open enrollment period(s), the State will accept requests from families interested in participating in the program. The State Medicaid Agency understands that waiver openings are based on the approved Factor C and that it has the responsibility of amending the waiver if it finds it necessary to reduce the maximum number of participants because legislative appropriations are insufficient to support the number of persons specified in the approved waiver. The State Medicaid Agency understands that in order to implement such a reduction, the State must submit a waiver amendment and the amendment must be formally approved by CMS. Applications will be sorted by geographical area and randomized, each geographical area receiving a representative number of waiver openings based upon population statistics from the 2010 US Census. Level of care is then evaluated for these individuals, and for those that meet level of care requirements, applications for Medicaid are provided to the Department of Workforce Services. This process ensures equal representation on the program throughout the state and protects openings for rural and underserved areas. The SMA will also hold reserve applications, at a ratio of 4:1 (reserves vs. enrolled) in order to quickly fill openings created through attrition. As openings are filled, the regional representation will be maintained when possible. Additional open enrollment periods may also be used. If there is an instance where sufficient applicants are not available from a specific geographic region to fill all waiver openings, the openings will be allocated to a neighboring area with an attempt to maintain the urban or rural demographics from the area in which the openings originated. Open application periods will be extended until the unduplicated count for that year is reached. It is not the intention to have any additional open enrollment periods during the waiver renewal as the Utah State Medicaid Agency is attempting to phase out the Autism Waiver Program. The SMA is planning to continue services for children who are on the waiver, and phase out the program as participants age out of the program at the completion of their seventh birthday.

Appendix B: Participant Access and Eligibility

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

1. The waiver is being (select one):

   Phased-in

   Phased-out

2. Phase-In/Phase-Out Time Schedule. Complete the following table:

   Beginning (base) number of Participants:

   Phase-In/Phase-Out Schedule
   Waiver Year 1 Unduplicated Number of Participants: 229 Month Base Number of Participants Change Participant Limit 1Oct 229 229 2Nov 229 217 3Dec 217 209 4Jan 209 200 5Feb 200 194 6Mar 194 183 7Apr 183 173 8May 173 164 9Jun 164 158 10Jul 158 153 11Aug 153 147 12Sep 147 135	Waiver Year 2 Unduplicated Number of Participants: 125 Month Base Number of Participants Change Participant Limit 1Oct 135 125 2Nov 125 117 3Dec 117 109 4Jan 109 100 5Feb 100 92 6Mar 92 87 7Apr 87 79 8May 79 70 9Jun 70 64 10Jul 64 55 11Aug 55 52 12Sep 52 49
   Waiver Year 3 Unduplicated Number of Participants: 41 Month Base Number of Participants Change Participant Limit 1Oct 49 41 2Nov 41 36 3Dec 36 32 4Jan 32 29 5Feb 29 27 6Mar 27 26 7Apr 26 24 8May 24 22 9Jun 22 19 10Jul 19 18 11Aug 18 17 12Sep 17 16	Waiver Year 4 Unduplicated Number of Participants: 13 Month Base Number of Participants Change Participant Limit 1Oct 16 13 2Nov 13 13 3Dec 13 13 4Jan 13 11 5Feb 11 9 6Mar 9 7 7Apr 7 6 8May 6 5 9Jun 5 3 10Jul 3 3 11Aug 3 2 12Sep 2 2
   Waiver Year 5 Unduplicated Number of Participants: 1 Month Base Number of Participants Change Participant Limit 1Oct 2 1 2Nov 1 1 3Dec 1 0 4Jan 0 0 5Feb 0 0 6Mar 0 0 7Apr 0 0 8May 0 0 9Jun 0 0 10Jul 0 0 11Aug 0 0 12Sep 0 0
3. Waiver Years Subject to Phase-In/Phase-Out Schedule

   Year One	Year Two	Year Three	Year Four	Year Five

4. Phase-In/Phase-Out Time Period

   	Month	Waiver Year
   Waiver Year: First Calendar Month	Oct
   Phase-in/Phase-out begins	Nov	1
   Phase-in/Phase-out ends	Dec	5

Appendix B: Participant Access and Eligibility

B-4: Eligibility Groups Served in the Waiver

1. 1. State Classification. The State is a (select one):
       §1634 State
       SSI Criteria State
       209(b) State
       not selected
   2. Miller Trust State.
      Indicate whether the State is a Miller Trust State (select one):
       No
       Yes
       Unknown
2. 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:

    not selected
   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
   Medically needy in 209(b) States (42 CFR §435.330)
   Medically needy in 1634 States and SSI Criteria States (42 CFR §435.320, §435.322 and §435.324)
   Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver)

   Specify:

   Character Count: out of 6000

   42 CFR 435.118, 435.135, 435.308 §1902(a)(10)(A)(ii)(XVII), §1902(a)(10)(A)(ii)(VIII).
   Special home and community-based waiver group under 42 CFR §435.217) Note: When the special home and community-based waiver group under 42 CFR §435.217 is included, Appendix B-5 must be completed
    No. The State does not furnish waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217. Appendix B-5 is not submitted.

    Yes. The State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217.

    not selected

   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

    not selected

   Check each that applies:

   A special income level equal to:

   Select one:

    300% of the SSI Federal Benefit Rate (FBR)

    A percentage of FBR, which is lower than 300% (42 CFR §435.236)

   Specify percentage:

    A dollar amount which is lower than 300%.

   Specify dollar amount:

    not selected

   Aged, blind and disabled individuals who meet requirements that are more restrictive than the SSI program (42 CFR §435.121)

   Medically needy without spenddown in States which also provide Medicaid to recipients of SSI (42 CFR §435.320, §435.322 and §435.324)

   Medically needy without spend down in 209(b) States (42 CFR §435.330)

   Aged and disabled individuals who have income at:

   Select one:

    100% of FPL

    % of FPL, which is lower than 100%.

   Specify percentage amount:

    not selected

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

   Specify:

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (1 of 7)

In accordance with 42 CFR §441.303(e), Appendix B-5 must be completed when the State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217, as indicated in Appendix B-4. Post-eligibility applies only to the 42 CFR §435.217 group.

1. 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 post-eligibility 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).
    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 elects to (select one):

    Use spousal post-eligibility rules under §1924 of the Act.

   (Complete Item B-5-b (SSI State) and Item B-5-d)

    Use regular post-eligibility rules under 42 CFR §435.726 (SSI State) or under §435.735 (209b State)

   (Complete Item B-5-b (SSI State). Do not complete Item B-5-d)

    not selected

    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-b (SSI State). Do not complete Item B-5-d)

    not selected

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (2 of 7)

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:

   1. 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:

       not selected

       A percentage of the Federal poverty level

      Specify percentage:

       Other standard included under the State Plan

      Specify:

      Character Count: out of 36000

       not selected
       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:

      Character Count: out of 6000

      The allowance for the personal needs of the waiver participant is 100% of the HHS Poverty Guidelines for one person plus a disregard for earned income up to the substantial gainful activity level of earnings defined in Section 223(d)(4) of the Compilation of the Social Security Laws in effect April 4, 2012, to determine countable earned income. Should the waiver client have other family members at home, an additional amount in recognition of higher expenses that a waiver client may have to meet the extra costs of supporting the other family members is allowed. The additional amount is the difference between the allowance for a family member defined in Section 1924(d) (1) (C) of the Social Security Act and the allowance for a family member defined in 42 CFR435.726(c)(3).
       Other

      Specify:

      Character Count: out of 6000
       not selected

   2. 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:

      Character Count: out of 6000

      Specify the amount of the allowance (select one):

       SSI standard

       Optional State supplement standard

       Medically needy income standard

       The following dollar amount:

      Specify dollar amount: If this amount changes, this item will be revised.

       The amount is determined using the following formula:

      Specify:

      Character Count: out of 6000

       not selected
       not selected

   3. 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:

      Character Count: out of 6000
       Other

      Specify:

      Character Count: out of 6000
       not selected

   4. Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 §CFR 435.726:

      1. Health insurance premiums, deductibles and co-insurance charges
      2. 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:

      Character Count: out of 6000

      The limits specified in Utah's title XIX state plan for post-eligibility income deductions under 42 CFR 435.725, 435.726, 435.832, and Sec. 1924 of the Social Security Act. The limits are defined on supplement 3 to Attachment 2.6A.
       not selected

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (3 of 7)

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

   Answers provided in Appendix B-4 indicate that you do not need to complete this section and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (4 of 7)

4. 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 community-based 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).

   1. Allowance for the personal needs of the waiver participant

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

      Specify percentage:
       The following dollar amount:

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

      Specify formula:

      Character Count: out of 4000

      The allowance for the personal needs of the waiver participant is: 100% of the HHS Poverty Guidelines for one person plus a disregard for earned income up to the substantial gainful activity level of earnings defined in Section 223(d)(4) of the Compilation of the Social Security Laws in effect April 4, 2012, to determine countable earned income.
       Other

      Specify:

      Character Count: out of 36000
       not selected

   2. 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:

      Character Count: out of 6000

      We added an additional amount to the allowance for the personal needs of a waiver participant without a community spouse to recognize the extra costs of supporting the other family members. The additional amount is the difference between the allowance for a family member defined in Section 1924(d) (1) (C) of the Social Security Act and the allowance for a family member defined in 42 CFR435.726(c)(3).
       not selected

   3. Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 CFR §435.726:

      1. Health insurance premiums, deductibles and co-insurance charges
      2. Necessary medical or remedial care expenses recognized under State law but not covered under the State's Medicaid plan, subject to reasonable limits that the State may establish on the amounts of these expenses.

      Select one:

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

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (5 of 7)

5. Regular Post-Eligibility Treatment of Income: SSI State - 2014 through 2018.

   Answers provided in Appendix B-5-a indicate that you do not need to complete this section and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (6 of 7)

6. Regular Post-Eligibility Treatment of Income: 209(B) State - 2014 through 2018.

   Answers provided in Appendix B-5-a indicate that you do not need to complete this section and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (7 of 7)

7. 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).

   Answers provided in Appendix B-5-a indicate that you do not need to complete this section and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-6: Evaluation/Reevaluation of Level of Care

1. Reasonable Indication of Need for Services. In order for an individual to be determined to need waiver services, an individual must require: (a) the provision of at least one waiver service, as documented in the service plan, and (b) the provision of waiver services at least monthly or, if the need for services is less than monthly, the participant requires regular monthly monitoring which must be documented in the service plan. Specify the State's policies concerning the reasonable indication of the need for services:

   1. 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:
   2. 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:

      Character Count: out of 4000

      Quarterly
       not selected
2. Responsibility for Performing Evaluations and Reevaluations. Level of care evaluations and reevaluations are performed (select one):
    Directly by the Medicaid agency
    By the operating agency specified in Appendix A
    By an entity under contract with the Medicaid agency.

   Specify the entity:

   Character Count: out of 4000
    Other
   Specify:

   Character Count: out of 4000
    not selected
3. 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:

   Character Count: out of 6000
   Operating Agency Waiver Support Coordinator – QIDP Qualified support coordinators shall possess at least a Bachelor degree in nursing, behavioral science or a human services related field such as social work, sociology, special education, rehabilitation counseling, or psychology and has at least one year of experience working directly with persons with intellectual disabilities or other developmental disabilities. Support coordinators must also demonstrate competency relating to the planning and delivery of health services to the waiver population through successful completion of a training program approved by the State Medicaid Agency. An individual with a “Bachelor degree in a human services related field” means an individual who has received: at least a Bachelor degree from a college or university (master and doctorate degrees are also acceptable) and has received academic credit for a minimum of 20 credit hours of coursework concentration in a human services field, as defined above. Although a variety of degrees may satisfy the requirements, majors such as geology and chemical engineering are not acceptable.
4. 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.

   Character Count: out of 12000
   Utah Administrative Rule 414-502-8 defines the State’s level of care criteria for intermediate care facilities for persons with intellectual disabilities. The rule defines that a client must: (1) Have a diagnosis of intellectual disability (42 CFR 483.102(b)(3) or a condition closely related to intellectual disability (42 CFR 435.1010) and (2) The Department considers a child under the age of seven to be at risk for functional limitation in three or more areas of major life activity, if the child has a diagnosis of intellectual disability or a condition closely related to intellectual disability. Autism spectrum disorder is considered to be a condition closely related to intellectual disability.
5. 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.

   Character Count: out of 12000

   The Medicaid Autism Waiver Level of Care form was created specifically for the purpose of evaluating LOC for this waiver. The form and process are different from the process and instruments used to determine LOC for institutional care. The tools used to determine level of care are different due to the ages of the children eligible for this waiver; children aged 2 – 6 with an ASD diagnosis. Because these children are a sub-set of those who would typically receive ICF/ID services, the tool used is detailed to confirm the diagnosis of ASD. A child with an ASD diagnosis within the age range specified in this waiver qualifies for ICF/ID level of care as per R414-502-8. •For institutional level of care (which is typically evaluated for individuals other than very young children) a single evaluation instrument is not used, rather a variety of histories and evaluations are used: -Assessments that document functional limitations in three of the major areas of life activity. -Social History and/or Social Summary which has been completed by the applicant or for the applicant no longer than one year prior to the date of application. -Psychological or Special Education Evaluation completed no longer than 5 years prior to the date of original waiver eligibility determination. -Medical Nursing Evaluation which has been completed by a physician or registered nurse no longer than one year prior to the date of original eligibility determination. (This form is only required for cases in which the person has specific medical conditions that are complex and/or may require additional services to meet the individual’s specific medical needs. -Documentation of date of onset of intellectual disability or related condition.
    not selected
6. 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:

   Character Count: out of 12000
   The child’s initial assessment will be completed using the level of care form developed in addition to any clinical evaluations and/or medical records that confirm the autism spectrum disorder diagnosis. Annual reevaluation assessments will be conducted in the same fashion.
7. 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:

   Character Count: out of 4000
    not selected
8. 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:

   Character Count: out of 6000
    not selected
9. 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):

   Character Count: out of 6000
   Timely re-evaluations will occur based on directives to operating agency staff who are employed as support coordinators to schedule re-evaluation events for each child on their caseload through the state calendaring software as an upcoming appointment.
10. 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:

    Character Count: out of 6000
    Records of evaluation/re-evaluation will be maintained for a minimum of three years at the State office administration building located at 195 North 1950 West, Salt Lake City, Utah.

Appendix B: Evaluation/Reevaluation of Level of Care

Quality Improvement: Level of Care

1. 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.

   1. Sub-Assurances:

      1. Sub-assurance: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future.

         Performance Measures

         For each performance measure the 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: The number and percentage of level of care evaluations that are conducted for new enrollees prior to receiving waiver services. (Numerator=# of level of care evaluations conducted for new enrollees; Denominator=Total # of new enrollees reviewed) Data Source (Select one): Other If 'Other' is selected, specify: DSPD Records Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

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

         Performance Measures

         For each performance measure the 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: Number and percentage of participants for whom a level of care evaluation was conducted at a minimum of annually within the calendar month in which it is due. (Numerator=# of LOCs completed timely; Denominator=Total # of LOCs required within review period) Data Source (Select one): Other If 'Other' is selected, specify: LOC Forms Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      3. Sub-assurance: The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant level of care.

         Performance Measures

         For each performance measure the 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: Number and percentage of participants for whom the level of care determination form accurately documents the LOC criteria based on clinical evaluations and/or medical records that confirm the autism spectrum disorder diagnosis. (Numerator=# of LOCs that accurately document clinical evaluations confirming an ASD Diagnosis; Denominator=Total # of LOCs reviewed) Data Source (Select one): Other If 'Other' is selected, specify: Participant Case File Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: The number and percentage of participants for whom the level of care is accurately documented on the level of care form described in the State Implementation Plan. (Numerator=# of LOC forms accurately documenting LOC; Denominator=Total # of LOC forms reviewed Data Source (Select one): Other If 'Other' is selected, specify: LOC Form Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: # and % of newly enrolled participants for whom Form 927 “Home and Community-Based Waiver Referral Form” documented the effective date of the applicant’s Medicaid eligibility determination and the effective date of the applicant’s level of care eligibility determination. (Numerator= # of 927 forms that accurately document Medicaid eligibility; Denominator=Total # of 927 forms reviewed) Data Source (Select one): Other If 'Other' is selected, specify: 927 Form Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: Number and percentage of participants for whom an assessment for level of care was conducted by a Qualified Intellectual Disabilities Professional. (Numerator = # of assessments completed by a QIDP; Denominator = # of total assessments completed) Data Source (Select one): Other If 'Other' is selected, specify: Participant Case Files/Employee Records Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 95% confidence interval, 5% margin of error Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

   2. 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.
      Character Count: out of 6000
      The SMA and DSPD will both conduct reviews of level of care determinations. The findings from all reviews conducted by DSPD will be submitted to the SMA for review and approval. An annual review will be conducted for each of the five waiver years. A base line review will be conducted after completion of the first waiver year. The sample size for this review will be sufficient to provide a confidence level equal to 95%, a confidence interval equal to 5 and a response distribution equal to 50%. The response distribution percentage for future reviews will reflect the findings gathered during the base line review.
2. Methods for Remediation/Fixing Individual Problems
   1. 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.
      Character Count: out of 6000
      Individual issues identified by the SMA and the OA, that affect the health and welfare of individual participants are addressed immediately. Issues that are less immediate are corrected within designated time frames, the results of which will be documented in the SMA final report.
   2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)

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

3. 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.

    No

    Yes

    not selected
   Please provide a detailed strategy for assuring Level of Care, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

B-7: Freedom of Choice

1. 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).
   Character Count: out of 12000
   Freedom of Choice is documented on the Form 818. Freedom of choice procedures: 1. When an individual is determined eligible for waiver services, the individual and the individual’s legal representative, if applicable, will be informed of the alternatives available under the waiver and offered the choice of institutional care (ICF/ID) or home and community-based care. A copy of the DSPD publication AN INTRODUCTORY GUIDE—Division of Services for People with Disabilities (hereafter referred to as the Guide), which describes the array of services and supports available in Utah including intermediate care facilities for persons with intellectual disabilities and the Medicaid Autism Waiver program, is given to each individual applying for waiver services. In addition, individuals will be given a 2-sided Informational Fact Sheet (Form IFS-10) which describes the eligibility criteria and services available through both the waiver program and through ICFs/ID. 2. The support coordinator will offer the choice of waiver services only if: a. The individual's needs assessment indicates the services the individual requires, including waiver services, are available in the community. b. The individual’s service plan has been agreed to by all parties. c. The health and safety of the individual can be adequately protected in relation to the delivery of waiver services and supports. 3. Once the individual has chosen home and community-based waiver services, the choice has been documented by the support coordinator, and the individual has received a copy of the Guide and the Informational Fact Sheet, subsequent review of choice of program will only be required at the time a substantial change in the enrollee’s condition results in a change in the individual’s service plan. It is, however, the individual’s option to choose institutional (ICF/ID) care at any time during the period they are in the waiver. 4. The waiver enrollee, and the individual’s legal representative if applicable, will be given the opportunity to choose the providers of waiver services identified on the Person Centered Support Plan if more than one qualified provider is available to render the services. The individual’s choice of providers will be documented in the individual’s service plan.
2. 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.
   Character Count: out of 4000
   Copies of the form will be maintained in the participant’s case file maintained by the support coordinator within the Division of Services for People with Disabilities.

Appendix B: Participant Access and Eligibility

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

Appendix C: Participant Services

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

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

   Service Type	Service
   Statutory Service	Respite
   Supports for Participant Direction	Financial Management Services

Appendix C: Participant Services

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

2. Provision of Case Management Services to Waiver Participants. Indicate how case management is furnished to waiver participants (select one):
    not selected
    Not applicable - Case management is not furnished as a distinct activity to waiver participants.
    Applicable - Case management is furnished as a distinct activity to waiver participants.
   Check each that applies:

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

   As a Medicaid State plan service under §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. NOTE: Pursuant to CMS-2237-IFC this selection is no longer available for 1915(c) waivers.

   Not applicable - Case management is not furnished as a distinct activity to waiver participants. Do not complete item C-1-c.
    None of the above apply - Case management is furnished as a waiver service (Do not complete item C-1-c).

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

   Character Count: out of 4000
   Support coordinators employed by the Division of Services for People with Disabilities conduct case management activities on behalf of waiver participants as an administrative function.

Appendix C: Participant Services

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

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

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

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

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

   Character Count: out of 12000

   UCA 62A-2-120 and Utah Administrative Code R501-14 requires all persons having direct access to children or vulnerable adults must undergo a criminal history/background investigation except in the case where the waiver enrollee has chosen to self-employ a family member as part of their self-directed program. If the person has lived in Utah continuously for 5 years or more a regional check is conducted. For those who have not lived in Utah for 5 continuous years a national check through the FBI is conducted. The Office of Licensing, an agency within the Utah Department of Human Services has the responsibility of conducting background checks on all direct care workers who provide waiver services. The scope of the investigation includes a check of the State’s child and adult abuse registries, and a Criminal History check through the Criminal Investigations and Technical Services Division of the Department of Public Safety. If a person has lived within two to five years outside the State of Utah or in foreign countries the FBI National Criminal History Records and National Criminal History will be accessed to conduct a check in those states and countries where the person resided. For providers under the Self-Administered Service Model, the state will withhold payments for services for anyone who has not completed a background check. DSPD keeps a database on all approved employees. A client has the option of having a criminal background check completed on a family member if they choose to, but it is not required. The health and safety of clients are ensured by routinely scheduled face-to-face visits by support coordinators, and by quality monitoring reviews by both the operating agency and the SMA. For those receiving Self-Administered Services (SAS), the FMS agency assists the family and the chosen employee to collect needed information and complete the background check application, but the actual background check is completed by the Office of Licensing.

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

   No. The State does not conduct abuse registry screening.

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

   Specify: (a) the entity (entities) responsible for maintaining the abuse registry; (b) the types of positions for which abuse registry screenings must be conducted; and, (c) the process for ensuring that mandatory screenings have been conducted. 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):

   Character Count: out of 12000

   Utah Code (Annotated) 62A-2-121, 122 and R501-14 of the Utah Administrative Code require all persons having direct access to children or vulnerable adults must undergo an abuse screening except in the case where the waiver enrollee has chosen to self-employ a family member as part of their self-directed program. The Utah Division of Aging and Adult Services and The Utah Division of Child and Family Services maintain these abuse registries. A designated staff person within DHS, Office of Licensing, completes all screenings. DSPD maintains a database on all approved employees. DSPD will not approve continued employment or provider payments if the required screenings have not been completed.

Appendix C: Participant Services

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

3. 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.

   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).

Appendix C: Participant Services

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

4. 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-1/C-3 the personal care or similar services for which payment may be made to legally responsible individuals under the State policies specified here.

   Character Count: out of 12000
    not selected

5. 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.

   Character Count: out of 12000
    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.

   Character Count: out of 12000

   As per Administrative Rule R539-5-5 parents, step-parents and legal guardians are not permitted to provide waiver services. Relatives, other than those listed above, may provide specified waiver services. The same payment controls are employed as described in Appendix E-1:1. Relatives may not provide services to multiple participants at the same time. Since parents, step parents and legal guardians are not permitted to provide waiver services, the State avoids the problem of having those with decision making authority also providing services. For Relatives: Support coordinators conduct monthly reviews of all services provided before claims are paid. Support coordinators monitor the use of services as defined in the Care Plan. DSPD conducts random sample audits each year on the SAS programs that focus on service usage and interviews with clients and employees about service utilization. DSPD monitors service utilization each month and notifies the quality management units if there is any indication of fraud or abuse of funds - for more in-depth audits to be completed.
    Other policy.

   Specify:

   Character Count: out of 12000
    not selected

6. 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:

   Character Count: out of 12000
   The Utah Department of Health will enter into a provider agreement with all willing providers who are selected by recipients and meet licensure, certification, competency requirements and all other provider qualifications. The Utah Department of Human Services in conjunction with the Bureau of Contract Management will issue a Statement of Interested and Qualifications (SOIQ) for the purpose of entering into a contract with willing and qualified individuals and public or private organizations. The SOIQ is distributed to all qualified providers and remains open, allowing for continuous recruitment. The request includes service requirements and expectations. A review committee evaluates the proposals against the criteria contained in the SOIQ and selects those who meet the qualifications.

Appendix C: Participant Services

Quality Improvement: Qualified Providers

1. 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.

   1. Sub-Assurances:

      1. 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.

         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: The number and percentage of providers that meet DSPD provider contract criteria, both initially and ongoing.(Numerator=# of providers that meet DSPD provider contract criteria; Denominator=Total# of DSPD providers reviewed ) Data Source (Select one): Other If 'Other' is selected, specify: DSPD contract reviews Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Source (Select one): Other If 'Other' is selected, specify: Provider staff interviews Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

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

         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: Number and percentage of providers of respite services under the Self-Administered Services (SAS) Model who have undergone a background check prior to providing services as required by the SIP.(Numerator=# of SAS respite providers who’ve undergone a background check prior to providing services; Denominator: Total # of SAS respite providers.reviewed) Data Source (Select one): Other If 'Other' is selected, specify: DSPD records Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: Number and percentage of providers of respite services under the Self-Administered Services (SAS) Model who have undergone an abuse screening through the State’s abuse registry as required by the SIP.(Numerator=# of SAS respite providers who’ve undergone an abuse screening; Denominator: Total # of SAS respite providers reviewed) Data Source (Select one): Other If 'Other' is selected, specify: DSPD Records Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      3. 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.

         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: Number and percentage of waiver participant representatives who were informed of their employer responsibilities to train each of their Self- Administered Service (SAS) providers .(Numerator=# of waiver participant representatives who were informed of their employer responsibilities to train each SAS respite provider. Denominator=# of SAS respite providers reviewed). Data Source (Select one): Other If 'Other' is selected, specify: SAS Agreement/DSPD Records Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

   2. 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.
      Character Count: out of 6000
      DSPD quality management team members conduct annual provider reviews which include monitoring all criteria in the provider contract of agency based providers of Medicaid Autism Waiver services. When deficiencies are identified, plans of correction are required and implemented within designated time frames. All DSPD reviews and plans of correction are submitted to the SMA for review and approval. In addition, DSPD support coordinators monitor SAS providers by monitoring payments, reviewing actual expenditures in comparison with the individual service plan budget, contacting the parent if any concerns arise and assisting in resolution of billing problems.
2. Methods for Remediation/Fixing Individual Problems
   1. 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.
      Character Count: out of 6000
      Individual provider issues identified during the contract reviews are corrected immediately by the provider or at a minimum within designated time frames. To assure issues have been corrected DSPD quality management team members monitor the implementation of plans of correction. Findings and corrections are documented in DSPD Final Reports.
   2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)

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

3. 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.

    No

    Yes

    not selected
   Please provide a detailed strategy for assuring Qualified Providers, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

   Character Count: out of 6000