Application for 1915(c) HCBS Waiver: UT.1246.R00.00

Application for a �1915(c) Home and Community-Based Services Waiver

PURPOSE OF THE HCBS WAIVER PROGRAM

The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in �1915(c) of the Social Security Act. The program permits a State to furnish an array of home and community-based services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. The State has broad discretion to design its waiver program to address the needs of the waiver�s target population. Waiver services complement and/or supplement the services that are available to participants through the Medicaid State plan and other federal, state and local public programs as well as the supports that families and communities provide.

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

Application for a �1915(c) Home and Community-Based Services Waiver

1. Request Information (1 of 3)

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).
Program Title (optional - this title will be used to locate this waiver in the finder):

Medically Complex Children's Waiver
Type of Request: new

Requested Approval Period:(For new waivers requesting five year approval periods, the waiver must serve individuals who are dually eligible for Medicaid and Medicare.)

3 years 5 years

New to replace waiver

Replacing Waiver Number:

Migration Waiver - this is an existing approved waiver

Provide the information about the original waiver being migrated

Base Waiver Number:

Amendment Number

(if applicable):

Effective Date: (mm/dd/yy)

Waiver Number:UT.1246.R00.00

Draft ID:UT.035.00.00
Type of Waiver (select only one):
Proposed Effective Date: (mm/dd/yy)

Approved Effective Date: 10/01/15

1. Request Information (2 of 3)

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

1. Request Information (3 of 3)

2. Brief Waiver Description

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

Character Count: out of 6000

The purpose of the Medically Complex Children’s Waiver (MCCW) is to offer supportive services statewide to individuals who meet waiver eligibility criteria and to assist these individuals to live as independently and productively as possible.

The Department of Health, Division of Medicaid and Health Financing will be responsible for the administration and daily operations of the waiver.  

The MCCW will offer both agency-based and self-directed services.

3. Components of the Waiver Request

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

Waiver Administration and Operation. Appendix A specifies the administrative and operational structure of this waiver.
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.
Participant Services. Appendix C specifies the home and community-based waiver services that are furnished through the waiver, including applicable limitations on such services.
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).
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
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.
Participant Safeguards. Appendix G describes the safeguards that the State has established to assure the health and welfare of waiver participants in specified areas.
Quality Improvement Strategy. Appendix H contains the Quality Improvement Strategy for this waiver.
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.
Cost-Neutrality Demonstration. Appendix J contains the State's demonstration that the waiver is cost-neutral.

4. Waiver(s) Requested

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.
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
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

In accordance with 42 CFR �441.302, the State provides the following assurances to CMS:

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.
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.
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.
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.
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.
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.
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.
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.
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.
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

Note: Item 6-I must be completed.

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.
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.
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.
Access to Services. The State does not limit or restrict participant access to waiver services except as provided in Appendix C.
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.
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.
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.
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.
Public Input. Describe how the State secures public input into the development of the waiver:

Character Count: out of 6000

The State Medicaid Agency convened a workgroup comprised of advocates, family members of children with complex medical conditions and staff from the Department of Health, Division of Medicaid and Health Financing, Bureau of Authorization and Community Based Services, and the Division of Family Health and Preparedness, Bureau of Children with Special Health Care Needs. The workgroup met on four occasions during April and May 2015. To introduce the new waiver proposal, the State met with the Utah Indian Health Advisory Board (UIHAB) on May 8, 2015. The State held a public meeting at the Department of Health on May 18, 2015. Online participation was available for those who could not attend in person. The meeting was announced through the Utah Public Notice Website at: http://www.utah.gov/pmn/index.html The State provided information about the waiver to the Medical Care Advisory Committee (MCAC) on May 18, 2015. Electronic and hard copies of the full draft application were available for public review from May 22 through June 22, 2015. An electronic copy of the full draft application was sent to a wide network of providers, consumers, governmental entities and other interested stakeholders including the UIHAB, MCAC, Utah Legislative Coalition for People with Disabilities, Utah Statewide Independent Living Council, Utah Developmental Disabilities Council and the Utah Disability Law Center for review. The proposed application was also posted on the State Medicaid Agency’s website at http://www.health.utah.gov/ltc/. Hard copies of the full draft application were available by calling the Utah Department of Health and requesting a hard copy by mail. Hard copies were also available by visiting the local offices of the Division of Services for people with Disabilities throughout the State. Non-electronic notification was achieved by posting a notice regarding how to access full copies (either electronic or hard copies) of the draft application in the Salt Lake Tribune and Deseret New. The newspaper notice also provided information on how to submit public comment. The State received one comment from a member of the public during the comment period. This comment was in support of the new waiver program and no changes were made to the implementation plan as a result.
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.
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)

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:
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

This document, together with Appendices A through J, constitutes the State's request for a waiver under §1915(c) of the Social Security Act. The State assures that all materials referenced in this waiver application (including standards, licensure and certification requirements) are readily available in print or electronic form upon request to CMS through the Medicaid agency or, if applicable, from the operating agency specified in Appendix A. Any proposed changes to the waiver will be submitted by the Medicaid agency to CMS in the form of waiver amendments.

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

Signature:

State Medicaid Director or Designee

Submission Date:

Note: The Signature and Submission Date fields will be automatically completed when the State Medicaid Director submits the application.

Last Name:

First Name:

Title:

Agency:

Address:

Address 2:

City:

State:

Utah

Zip:

Phone:

Ext: TTY

Fax:

E-mail:

Attachments

Attachment #1: Transition Plan

Specify the transition plan for the waiver:

Character Count: out of 12000

There is no transition plan for this waiver.  This is a new waiver that is in compliance with HCBS setting requirements.

Attachment #2: Home and Community-Based Settings Waiver Transition Plan

Specify the state's process to bring this waiver into compliance with federal home and community-based (HCB) settings requirements at 42 CFR 441.301(c)(4)-(5), and associated CMS guidance.

Consult with CMS for instructions before completing this item. This field describes the status of a transition process at the point in time of submission. Relevant information in the planning phase will differ from information required to describe attainment of milestones.

To the extent that the state has submitted a statewide HCB settings transition plan to CMS, the description in this field may reference that statewide plan. The narrative in this field must include enough information to demonstrate that this waiver complies with federal HCB settings requirements, including the compliance and transition requirements at 42 CFR 441.301(c)(6), and that this submission is consistent with the portions of the statewide HCB settings transition plan that are germane to this waiver. Quote or summarize germane portions of the statewide HCB settings transition plan as required.

Note that Appendix C-5 HCB Settings describes settings that do not require transition; the settings listed there meet federal HCB setting requirements as of the date of submission. Do not duplicate that information here.

Update this field and Appendix C-5 when submitting a renewal or amendment to this waiver for other purposes. It is not necessary for the state to amend the waiver solely for the purpose of updating this field and Appendix C-5. At the end of the state's HCB settings transition process for this waiver, when all waiver settings meet federal HCB setting requirements, enter "Completed" in this field, and include in Section C-5 the information on all HCB settings in the waiver.

Character Count: out of 60000

This is a new waiver that is in compliance with HCBS setting requirements.

Additional Needed Information (Optional)

Provide additional needed information for the waiver (optional):

Character Count: out of 60000

Appendix A: Waiver Administration and Operation

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:The Bureau of Authorization and Community Based Services, Division of Medicaid and Health Financing (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:
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

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:
  As indicated in section 1 of this appendix, the waiver is not operated by a separate agency of the State. Thus this section does not need to be completed.
  
  Character Count: out of 12000

Appendix A: Waiver Administration and Operation

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

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

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

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

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
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

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

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.
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 Medically Complex Children’s Waiver Program through numerous activities including 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 the Medically Complex Children’s Waiver operations. Approvals are accomplished through a formal document approval process. The SMA Quality Assurance Unit conducts an annual review of the Medically Complex Children’s Waiver Program for each of the three waiver years. At a minimum, one comprehensive review will be conducted during this three year cycle. The other annual reviews will be focused reviews. The criteria for the focused reviews will be determined from the Medically Complex Children’s Waiver Unit review findings as well as other issues that develop during the review year. The sample size for the first year review will be sufficient to provide a confidence level equal to 95%, a response distribution of 50%, and a confidence interval equal to 5. For future years, the State will request a lower response distribution based on the statistical evidence of previous reviews.

Methods for Remediation/Fixing Individual Problems

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 that affect the health and welfare of individual participants are addressed immediately. Issues requiring immediate attention are addressed in a variety of ways. Depending on the circumstances of the individual case the interventions could include: contacting the SMA Medically Complex Children’s Waiver Unit, case management and/or direct care provider agencies requiring an immediate review and remediation of the issue, reporting the issue to CPS and/or local law enforcement or the state’s Medicaid Fraud Control Unit, the licensing authority or the survey/certification authority. To assure the issue has been addressed, entities assigned the responsibility of review and remediation are required to report back to the SMA on the results of their interventions within designated time frames. A description of issues requiring immediate attention and outcomes are documented through the SMA Quality Assurance Unit's final report. Issues that are less immediate are corrected within designated time frames and are documented through the SMA Quality Assurance Unit's final review report. When the SMA determines that an issue is resolved, notification is provided and documentation is maintained by the SMA.

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:

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)

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
Target Group	Included	Target SubGroup	Minimum 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

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

Character Count: out of 12000

1) Have complex chronic medical conditions and medical fragility associated with disabilities, technology dependencies, ongoing involvement of multiple subspecialty services and providers and/or frequent or prolonged hospitalizations or skilled nursing facility stays. a) To determine if a child has the medical complexity and intensity of services required for program eligibility, the child must have had within the last 24 months from the date of program application, or since the birth of the child if the child is less than 24 months old: i) ≥ 3 organ systems affected; AND ii) Must have 3 out of 4 of items 1 through 4: (1) ≥ 3 physicians involved in the child’s care; (2) Prolonged dependence (> 3 months) on device-based support to compensate for inadequate organ or system function. (3) High utilization of medical therapies, treatments, or subspecialty services, defined as prolonged dependence (> 3 months) on any of the following: (a) Intravenous administration of nutritional substances or medications; or (b) Any other medical devices to compensate for vital bodily function; or (c) Child is not dependent on technology, but has any chronic medical condition that requires as great a level of care as the those listed in (a) through (c) such as: (i) As a consequence of the child’s medical condition, needs substantial physical assistance with activities of daily living (ADLs), such as mobility, feeding, toileting, dressing and bathing, at an age when the child would otherwise not be dependent; or (ii) Requires consistent medical or nursing supervision for monitoring results from the complexity of their condition. (4) Frequent need for medical intervention or consultation, such as (a) ≥ 10 days spent in an inpatient hospital or skilled nursing facility during the period; or (b) ≥ 8 emergency department visits related to the complex medical conditions during the period; or (c) ≥ 20 physician office visits or phone calls to the physician regarding the complex medical conditions during the period.
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

To begin transition planning, the waiver case manager will meet with the individual approximately one year prior to the individual’s reaching the maximum age limit. The case manager will present the individual with information about other home and community based waiver options for which the individual may be eligible, including application process information. The case manager will also facilitate a discussion between the individual and the Department of Workforce Services, Medicaid financial eligibility staff, to review the case to determine if the individual will continue to meet financial Medicaid eligibility requirements when determined via regular community Medicaid rules, rather than HCBS waiver financial eligibility rules.

Appendix B: Participant Access and Eligibility

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

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.

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
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)

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

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

Appendix B: Participant Access and Eligibility

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

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)

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.

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
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

Entrance to the waiver will be managed by open application periods. During the open enrollment period(s), the State will accept applications from interested applicants. (All references to applicants, participants or individuals within this document include the role of the individual’s representative). If the number of eligible applications received during the open application period is equal to or less than the “point in time” capacity declared in the approved waiver, all applicants will be enrolled onto the waiver and applications will continue to be accepted until capacity is reached. If the number of eligible applicants exceeds the declared point in time capacity, applications will be ranked based on a Medical Acuity and Critical Needs Grid Score. Individuals with the highest Grid Score will be enrolled until the declared point in time capacity is reached.

Appendix B: Participant Access and Eligibility

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

Answers provided in Appendix B-3-d indicate that you do not need to complete this section.

Appendix B: Participant Access and Eligibility

B-4: Eligibility Groups Served in the Waiver

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.

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)

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

Appendix B: Participant Access and Eligibility

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

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

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)

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

Appendix B: Participant Access and Eligibility

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

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

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

Answers provided in Appendix B-5-a indicate the selections in B-5-b also apply to B-5-e.

Appendix B: Participant Access and Eligibility

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

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

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

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 (7 of 7)

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

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 the selections in B-5-d also apply to B-5-g.

Appendix B: Participant Access and Eligibility

B-6: Evaluation/Reevaluation of Level of Care

As specified in 42 CFR �441.302(c), the State provides for an evaluation (and periodic reevaluations) of the need for the level(s) of care specified for this waiver, when there is a reasonable indication that an individual may need such services in the near future (one month or less), but for the availability of home and community-based waiver services.

Appendix B: Evaluation/Reevaluation of Level of Care

Quality Improvement: Level of Care

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

Methods for Discovery: Level of Care Assurance/Sub-assurances

The state demonstrates that it implements the processes and instrument(s) specified in its approved waiver for evaluating/reevaluating an applicant's/waiver participant's level of care consistent with level of care provided in a hospital, NF or ICF/IID.

Sub-Assurances:

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:

Number and percentage of new enrollees who meet level of care requirements prior to receiving services on the waiver. (Numerator = # of new recipients meeting level of care requirements; Denominator = total # of new enrollees).

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:

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.

Performance Measure:

Number and percentage of waiver recipients who received an annual level of care reevaluation within 12 months of the most current level of care evaluation and completed during the calendar month in which it is due. (Numerator = # of annual LOCs completed timely; Denominator = total # of annual LOCs required).

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:

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.

Performance Measure:

Number and Percentage of waiver recipients whose level of care screenings and evaluations were documented using the MDS/Medical Acuity and Critical Needs Grid. (Numerator = # of LOC determinations in compliance; Denominator = total # of LOC determinations made).

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 Level of Care evaluations (initial or annual) which were completed accurately based on Level of Care criteria. (Numerator=# of LOC evaluations completed accurately; Denominator=Total # of LOC evaluations completed).

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 Registered Nurse or Physician licensed in the state. (Numerator = # of assessments completed by an RN/Physician; Denominator = # of total assessments completed)

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:

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 RN case manager is responsible for confirming individuals meet level of care requirements for the program. Reviews of assessments and level of care determinations will be completed by the SMA QA Unit. An annual review will be conducted for each of the 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.

Methods for Remediation/Fixing Individual Problems

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 that affect the health and welfare of individual participants are addressed immediately. Issues that are less immediate are corrected within designated time frames and are documented through the final review report. When the SMA QA Unit determines that an issue is resolved, notification is provided and documentation is maintained.

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:

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

Freedom of Choice. As provided in 42 CFR �441.302(d), when an individual is determined to be likely to require a level of care for this waiver, the individual or his or her legal representative is:

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

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

Applicants and participants are informed of the choice between waiver services and nursing facility based care during their initial evaluation and each annual reevaluation thereafter. In addition, the individual is informed of feasible alternatives and offered the choice among waiver services and providers. The Initial and Annual Freedom of Choice Certification form is used to document the individual’s choices.
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

Initial and Annual Freedom of Choice Certification forms are maintained by the RN case manager in each participant’s case file.

Appendix B: Participant Access and Eligibility

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

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

Character Count: out of 12000

Medicaid providers are required to provide foreign language interpreters for Medicaid participants who have limited English proficiency.  Waiver participants are entitled to the same access to an interpreter to assist in making and attending appointments for qualified procedures on behalf of the participant.  Providers must notify participants that interpretive services are available at no charge.  The State Medicaid Agency encourages participants to use professional services rather than relying on a family member or friends though the final choice is theirs. Using an interpretive service provider ensures confidentiality as well as the quality of language translation. 

Information regarding access to Medicaid Translation Services is included in the Medicaid Member Guide distributed to all Utah Medicaid participants.  Eligible individuals may access translation services by calling the Medicaid Helpline.

For the full text of the Medicaid Member Guide, go to: http://health.utah.gov/umb/forms/pdf/mg_w_cover.pdf

Appendix C: Participant Services

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

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 Skilled Nursing Respite and Routine Respite

Supports for Participant Direction Financial Management Services

Service Type	Service
Statutory Service	Skilled Nursing Respite and Routine Respite
Supports for Participant Direction	Financial Management Services

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

Service:

Alternate Service Title (if any):

Skilled Nursing Respite and Routine Respite

HCBS Taxonomy:

Category 1:

Sub-Category 1:

Category 2:

Sub-Category 2:

Category 3:

Sub-Category 3:

Category 4:

Sub-Category 4:

Service Definition (Scope):

Skilled Nursing Respite is an intermittent service provided by a registered nurse to a participant to relieve the primary caregiver from the stress of providing continuous skilled care, thereby avoiding premature or unnecessary nursing facility admission.  Skilled Nursing Respite services may be provided by a Medicaid enrolled Home Health Agency or through the Self Directed Method.  
Skilled Nursing Respite is provided in a private residence or other setting(s) in the community, outside of the participant’s home, but only when the participant, the RN cases manager and the respite care provider (individual or agency) have agreed and stipulated in the care plan that the alternative setting(s) is safe and can accommodate the necessary medical equipment and personnel needed to safely care for the participant. The provision of respite service could also occur in settings such as parks, libraries, the home of the participant, respite worker or another family member, etc.  Understanding the medical complexity of the waiver participants, it is believed the service provision will mainly be in-home.

Routine Respite is an intermittent service provided by a non-licensed, qualified provider to a participant to relieve the primary caregiver from the stress of providing continuous care, thereby avoiding premature or unnecessary nursing facility admission.  Routine Respite services may be provided by a Medicaid enrolled Home Health Agency or through the Self-Directed Services  Method.  
Routine Respite is provided in a private residence or other setting(s) in the community, outside of the participant’s home, but only when the participant, the RN cases manager and the respite care provider (individual or agency) have agreed and stipulated in the care plan that the alternative setting(s) is safe and can accommodate the necessary medical equipment and personnel needed to safely care for the participant. The provision of respite service could also occur in settings such as parks, libraries, the home of the participant, respite worker or another family member, etc.  Understanding the medical complexity of the waiver participants, it is believed the service provision will mainly be in-home. 

Respite services may not be provided in institutional settings, or in settings that are not compliant with the HCBS settings requirements found in 42 CFR 441.301(c).

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

This service is not available for ongoing daycare or childcare purposes and is not intended to be used for extended periods at one time.  Although limited variation in use of estimated weekly respite hours, listed on the approved care plan, is permissible, the participant cannot “bank” authorized weekly respite services to be used at a single time or for an extended period.  Typical utilization of respite services is estimated to be an average of three hours per week.  Six hours is the maximum number of respite hours that can be used on a single date of service.  Specific limits on the amount, frequency and duration of services are specified in the individual’s care plan and are based on assessed need.

Service Delivery Method (check each that applies):

Participant-directed as specified in Appendix E

Provider managed

Specify whether the service may be provided by (check each that applies):

Legally Responsible Person

Relative

Legal Guardian

Provider Specifications:

Provider Category	Provider Type Title
Individual	Routine Respite (Provided by non-licensed individuals) – Self- Directed Services Method
Agency	Skilled Nursing Respite - Agency Based
Individual	Skill Nursing Respite – Self Directed Services Method
Agency	Routine Respite (Provided by non-licensed individuals) - Agency Based

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Skilled Nursing Respite and Routine Respite

Provider Category:

Provider Type:

Routine Respite (Provided by non-licensed individuals) – Self- Directed Services Method

Provider Qualifications

License (specify):

Licensed in the State of Utah as a registered nurse in accordance with Title 58, Chapter 31b, Part 3, Occupational and Professional Licensing, Utah Code Annotated

Certificate (specify):

Other Standard (specify):

Completed Background and Criminal Investigation (BCI) check
Basic CPR certification
Enrolled with a Financial Management Services (FMS) Agency
Demonstrated ability to perform the necessary functions to safely care for the participant 
Completed  Self Directed Services Provider Agreement

Verification of Provider Qualifications

Entity Responsible for Verification:

State Medicaid Agency

Frequency of Verification:

Annual review to confirm the individual’s licensure.

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Skilled Nursing Respite and Routine Respite

Provider Category:

Provider Type:

Skilled Nursing Respite - Agency Based

Provider Qualifications

License (specify):

Licensed Home Health Agencies in accordance with UAC 432-700

Certificate (specify):

Medicare Certified

Other Standard (specify):

Agency must be enrolled as a Medicaid HCBS waiver provider.  Registered nurses employed by the home health agency must be licensed in the State of Utah as a registered nurse in accordance with Title 58, Chapter 31b, Part 3, Occupational and Professional Licensing, Utah Code Annotated.

Verification of Provider Qualifications

Entity Responsible for Verification:

State Medicaid Agency

Frequency of Verification:

Annual review to confirm the agency’s licensure.

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Skilled Nursing Respite and Routine Respite

Provider Category:

Provider Type:

Skill Nursing Respite –  Self Directed Services Method

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Current RN licensure
Completed Background and Criminal Investigation (BCI) check
Nursing Malpractice Insurance/Individual Professional Liability Insurance
Basic CPR certification
Enrolled with a Financial Management Services (FMS) Agency
Demonstrated ability to perform the necessary skilled nursing functions to safely care for the participant 
Completed  Self Directed Service Provider Agreement

Verification of Provider Qualifications

Entity Responsible for Verification:

State Medicaid Agency

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Skilled Nursing Respite and Routine Respite

Provider Category:

Provider Type:

Routine Respite (Provided by non-licensed individuals) - Agency Based

Provider Qualifications

License (specify):

Licensed Home Health Agencies in accordance with UAC 432-700

Certificate (specify):

Other Standard (specify):

Agency must be enrolled as a Medicaid HCBS waiver provider.

Verification of Provider Qualifications

Entity Responsible for Verification:

State Medicaid Agency

Frequency of Verification:

Annual review to confirm the agency’s licensure.

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

The waiver provides for participant direction of services as specified in Appendix E. Indicate whether the waiver includes the following supports or other supports for participant direction.

Support for Participant Direction:

Alternate Service Title (if any):

HCBS Taxonomy:

Category 1:

Sub-Category 1:

Category 2:

Sub-Category 2:

Category 3:

Sub-Category 3:

Category 4:

Sub-Category 4:

Service Definition (Scope):

Financial Management Service is offered in support of the self- directed services delivery option.  Services rendered under this definition include those to facilitate the employment of skilled nursing respite and routine respite service providers:
a) Provider qualification verification;
b) Employer-related activities including federal, state, and local tax withholding/payments, unemployment compensation fees, wage settlements, fiscal accounting and expenditure reports;
c) Medicaid claims processing and reimbursement distribution; and
d) Providing monthly accounting and expense reports to the participant.

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

Financial Management Services are intended to provide basic payroll services to Home and Community-Based Services waiver participants who elect the Self-Directed Services delivery option.    This service does not provide persons with assistance in managing their personal funds or budgets and does not provide representative payee services.  The participant is the sole employer.  The FMS provider is in no way an employer of the individuals providing respite services to the participant.

Service Delivery Method (check each that applies):

Participant-directed as specified in Appendix E

Provider managed

Specify whether the service may be provided by (check each that applies):

Legally Responsible Person

Relative

Legal Guardian

Provider Specifications:

Provider Category	Provider Type Title
Agency	Financial Management Services Agency

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Supports for Participant Direction

Service Name: Financial Management Services

Provider Category:

Provider Type:

Financial Management Services Agency

Provider Qualifications

License (specify):

Certified Public Accountant
UCA Sec 58-26A And 
UAC 156-26A

Certificate (specify):

Other Standard (specify):

•	Enroll as a Medicaid Provider 
•	Comply with all applicable State and Local licensing, accrediting, and certification requirements.
•	Understand the laws, rules and conditions that accompany the use of State and local resources and Medicaid resources.
•	Utilize accounting systems that operate effectively on a large scale as well as track individual budgets and do allow for payments that exceed amounts authorized on the care plan.
•	Utilize a claims processing system acceptable to the Utah State Medicaid Agency.
•	Establish time lines for payments that meet individual needs within DOL regulations.
•	Generate service management, and statistical information and reports as required by the Medicaid program.
•	Develop systems that are flexible in meeting the changing circumstances of the Medicaid program.
•	Provide needed training and technical assistance to participants, their representatives, and others.
•	Document required Medicaid provider qualifications and enrollment requirements and maintain results in provider/employee file.
•	Act on behalf of the person receiving services (the employer) and services for the purpose of payroll reporting.
•	Develop and implement an effective payroll system that addresses all related tax obligations.
•	Make related payments as approved in the person’s budget, authorized by the case management agency.
•	Generate payroll checks in a timely and accurate manner and in compliance with all federal and state regulations pertaining to “domestic service” workers.
•	Conduct background checks as required and maintain results in employee file.
•	Process all employment records.
•	Obtain authorization to represent the individual/person receiving supports.
•	Prepare and distribute an application package of information that is clear and easy for the individuals hiring their own staff to understand and follow.
•	Establish and maintain a record for each employee and process employee employment application package and documentation.
•	Utilize an accounting information system to invoice and receive Medicaid reimbursement funds.
•	Utilize an accounting and information system to track and report the distribution of Medicaid reimbursement funds.
•	Generate a detailed Medicaid reimbursement funds distribution report to the individual Medicaid recipient or representative semi-annually.
•	Withhold, file and deposit FICA, FUTA and SUTA taxes in accordance with federal IRS and DOL, and state regulations.
•	Generate and distribute IRS W-2’s. Wage and Tax Statements and related documentation annually to all support workers who meet the statutory threshold earnings amounts during the tax year by January 31st.
•	File and deposit federal and state income taxes in accordance with federal IRS and state rules and regulations.
•	Assure that employees are paid established unit rates in accordance with the federal and state Department of Labor Fair Labor Standards Act (FLSA)
•	Process all judgments, garnishments, tax levies or any related holds on an employee’s funds as may be required by local, state or federal laws.
•	Distribute, collect and process all employee time sheets as summarized on payroll summary sheets completed by the participant.
•	Prepare employee payroll checks, at least monthly, sending them directly to the employees.
•	Keep abreast of all laws and regulations relevant to the responsibilities it has undertaken with regard to the required federal and state filings and the activities related to being a Fiscal/Employer Agent.
•	Establish a customer service mechanism in order to respond to calls from participants (employers) and their employees regarding issues such as withholding and net payments, lost or late checks, reports and other documentation.
•	Customer service representatives are able to communicate effectively in English and Spanish by voice and TTY with people who have a variety of disabilities.
•	Have a Disaster Recovery Plan for restoring software and master files and hardware backup if management information systems are disabled so that payroll and invoice payment systems remain intact.
•	Regularly file and perform accounting auditing to ensure system accuracy and compliance with general accounting practice

Verification of Provider Qualifications

Entity Responsible for Verification:

State Medicaid Agency

Frequency of Verification:

Annual review to confirm the agency’s licensure.

Appendix C: Participant Services

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

The Bureau of Authorization and Community Based Services, Division of Medicaid and Health Financing, Utah Department of Health.

Appendix C: Participant Services

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

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

Criminal background investigations will be required for Self Directed Service providers. Verification of mandatory investigations will be the responsibility of the Financial Management Agency prior to the delivery of family directed services. The State will assure compliance with criminal background investigation process during quality assurance monitoring of the FMS providers. Utah Law 53-10-108 allows qualifying entities to request Utah criminal history information. The scope of investigation includes Utah Criminal History, Utah Statewide Warrant and Protective Orders and Federal Want and Warrant files.
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

Appendix C: Participant Services

C-2: General Service Specifications (2 of 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)

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
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

The State does not make payments to legally responsible individuals or legal guardians. The State does allow payments to relatives other than legally responsible individuals or legal guardians but only when the relative is qualified to provide services as specified in Appendix C-3. The State will not pay non-legally responsible caregivers to provide waiver services when they are already being paid by another source to care for the recipient (i.e., foster parents). On an ongoing basis, the RN case manager will verify that services provided are appropriate and furnished in the best interest of the recipient at the time a formal review of the care plan is completed, at least every six months or more frequently as necessary to ensure services continue to meet the needs of the waiver participant. Additionally, on an annual basis, Medicaid will complete a sample review of claims for waiver services rendered to verify the service was authorized and did not exceed the amounts authorized in the care plan. The State will use the sampling methodology required by CMS when calculating sample sizes. (Currently a 95% confidence interval, 5% margin of error and 50% response distribution). Care plans for those individuals will be compared to actual claims billed and recoupments initiated for those who had utilization exceeded authorized amounts.

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

Other policy.

Specify:

Character Count: out of 12000

not selected
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 State Medicaid Agency (SMA) will enter into a provider agreement with all willing providers who meet licensure, certification and/or other qualifications. The SMA will recruit providers in areas throughout the State. Interested providers are required to complete a Medicaid provider application and all required documentation verifying provider qualifications. Details about waiver provider qualifications and procedures for enrollment are available through the Utah Medicaid website at: http://medicaid.utah.gov All waiver providers, regardless of whether they are enrolled to provide Medicaid State plan services, must have a separate, signed Medicaid Application/Agreement on file with the SMA in order to provide and bill for MCCW services. Each new Medicaid Provider Application/Agreement must include all applicable licenses and certifications and must be reviewed and approved by BACBS. BACBS will submit the provider agreement/application to the Bureau of Medicaid Operations for processing and enrollment.

Appendix C: Participant Services

Quality Improvement: Qualified Providers

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

Methods for Discovery: Qualified Providers

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

Sub-Assurances:

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.

Performance Measure:

Number and percentage of agencies/individuals who meet required licensing standards, both at the time of enrollment and ongoing. (Numerator = # of provider agencies/individuals who meet requirements; Denominator = total # of providers reviewed).

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: Upon receipt of Survey Reports

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.

Performance Measure:

Number and percentage of providers of respite services under the Self-Directed Services Model who have undergone a background check prior to providing services as required by the SIP.(Numerator = # of Self Directed Service workers in compliance; Denominator = total # of Self Directed Service workers reviewed).

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:

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.

Performance Measure:

Number and percentage of providers of respite services under the Self- Directed Services Model who have received training by the parent of the waiver participant when warranted. (Numerator = # of Self Directed Service providers with documented training; Denominator = # of Self Directed Service providers who required training).

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:

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 MCCW Unit conducts an annual review of the Medically Complex Children’s Waiver program for each of the three waiver years. At a minimum, one comprehensive review involving the SMA QA Unit will be conducted during this three year cycle. The SMA QA Unit also has discretion to perform focused reviews as determined necessary. The criteria for the focused reviews will be determined from review findings as well as other issues that develop during the review year. The sample size for the first year review will be sufficient to provide a confidence level equal to 95%, a response distribution of 50%, and a confidence interval equal to 5. For future years, the State will request a lower response distribution based on the statistical evidence of previous reviews.

Methods for Remediation/Fixing Individual Problems

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 that affect the health and welfare of individual participants are addressed immediately. Issues that are less immediate are corrected within designated time frames and are documented through the SMA final review report. When the SMA QA Unit determines that an issue is resolved, notification is provided and documentation is maintained.

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:

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

Appendix C: Participant Services

C-3: Waiver Services Specifications

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

Appendix C: Participant Services

C-4: Additional Limits on Amount of Waiver Services

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

not selected

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

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

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

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

Furnish the information specified above.

Character Count: out of 24000

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

Furnish the information specified above.

Character Count: out of 24000

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

Furnish the information specified above.

Character Count: out of 24000

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

Describe the limit and furnish the information specified above.

Character Count: out of 24000

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

Appendix C: Participant Services

C-5: Home and Community-Based Settings

Explain how residential and non-residential settings in this waiver comply with federal HCB Settings requirements at 42 CFR 441.301(c)(4)-(5) and associated CMS guidance. Include:

Description of the settings and how they meet federal HCB Settings requirements, at the time of submission and in the future.
Description of the means by which the state Medicaid agency ascertains that all waiver settings meet federal HCB Setting requirements, at the time of this submission and ongoing.

Note instructions at Module 1, Attachment #2, HCB Settings Waiver Transition Plan for description of settings that do not meet requirements at the time of submission. Do not duplicate that information here.

Character Count: out of 60000

The MCCW is fully compliant with HCBS setting requirements.  MCCW Respite services are primarily provided in the participant's private residence. The provision of respite service could also occur in naturally occurring settings outside of the participant's home such as parks, libraries, the home of the respite worker or another family member, etc.  

Respite services may not be provided in institutional settings, or in settings that are not compliant with the HCBS settings requirements found in 42 CFR 441.301(c).

Understanding the medical complexity of the waiver participants, it is believed the service provision will mainly be in-home. Case managers will be responsible for oversight and ongoing monitoring of the settings in which waiver services are being provided. The FMS service is provided in support of Self- Directed Services.

Appendix D: Participant-Centered Planning and Service Delivery

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

State Participant-Centered Service Plan Title:

Person-Centered Care Plan

Responsibility for Service Plan Development. Per 42 CFR �441.301(b)(2), specify who is responsible for the development of the service plan and the qualifications of these individuals (select each that applies):

Registered nurse, licensed to practice in the State

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

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

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

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

Specify qualifications:

Character Count: out of 6000

Social Worker

Specify qualifications:

Character Count: out of 6000

Other

Specify the individuals and their qualifications:

Character Count: out of 6000

Appendix D: Participant-Centered Planning and Service Delivery

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

Service Plan Development Safeguards. Select one:

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

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

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

Character Count: out of 6000

Appendix D: Participant-Centered Planning and Service Delivery

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

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

Character Count: out of 12000

The Person-Centered Care Plan (PCCP) is developed in conjunction with the participant, parents, family members, or their legal representatives and other individuals of the participant’s choosing. RN case managers describe the waiver services and offer the choice between/among waiver services and providers. The waiver participant and those in their chosen circle of support are given a waiver information sheet for future reference. If the participant has chosen self- directed services, information to assist in the planning process will also be provided. The RN case manager reviews waiver services with the participant and their chosen circle of support each time the PCCP is updated.

Appendix D: Participant-Centered Planning and Service Delivery

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

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

Character Count: out of 24000

(a) The PCCP is developed by the RN case manager in conjunction with the participant and their chosen circle of supports. The RN case manager will discuss the service needs identified during the assessment and available waiver services to meet those needs. The RN case manager will review a list of available service providers and will discuss the self- directed services option. If the participant elects the self-directed services option, the RN case manager will provide training regarding the role and responsibilities involved with being an employer and the requirement for FMS to be a service that is included in the PCCP. Relative to the needs of the individual, the RN case manager will review both the skilled nursing and routine respite options and will discuss the types of tasks that must be performed by an RN versus those that can be performed by non-licensed personnel. With the information presented, the participant will make known their preferences about desired services and chosen service delivery method(s). The responsibilities of the RN case manager will be discussed including the requirement to assist with the implementation and monitoring of the PCCP. (b) The RN case manager conducts a comprehensive assessment which includes a review of medical/clinical documentation and completion of comprehensive assessment forms which include sections for documenting information related to: o Comprehensive health history; o Physicians/clinicians and others involved in the participant’s care; o Medical technology/device-based support; o d) Medical therapies, treatments and subspecialty services (includes hospitalizations and outpatient procedures; o Functional limitations; o Type and frequency of medical intervention and consultation; o Current home care services and providers; o Types of durable medical equipment; o Nutrition status and mode of nutritional intake; o Financial, SSI and private insurance information; o Recipient needs, risks, preferences, and goals; and o Any identified health and safety risks. o Strengths and Capacities (c) The RN case manager will review a list of available service providers and will discuss the self- directed services option. If the participant elects the self-directed services option, the RN case manager will provide training regarding the role and responsibilities involved with being an employer and the requirement for FMS to be a service that is included in the PCCP. Relative to the needs of the individual, the RN case manager will review both the skilled nursing and routine respite options and will discuss the types of tasks that must be performed by an RN versus those that can be performed. (d) PCCP development incorporates input from the participant and their circle of supports and includes offering the participant the choice of waiver providers when more than one provider is available to deliver the services. The participant and their circle of supports are an integral part of the waiver assessment and planning process. The planning meetings will be scheduled at a time and location convenient to the participant. The RN case manager continually assess changes in the participant's health status and family circumstances in order to identify if additional services may be needed. (e) RN case managers are responsible to oversee the coordination of waiver services. Participants may be referred and assisted with coordinating non-waiver services included in the PCCP; but the RN case manager is not responsible for ensuring their delivery. When non-waiver services are needed to meet the needs of the participant, the RN case manager assists, coordinates and monitors the implementation of the needed non-waiver services. (f) The RN case manager will discuss their responsibilities related to implementation and monitoring the PCCP. The participant will be instructed to contact the RN cases manager with any questions or concerns about services, coordination with other benefits or health and safety concerns. The participant will be instructed to report hospitalizations or other incidents involving the participant. The participant will be informed of the RN case manager’s authority to approve and coordinate waiver services. The RN case manager will support the participant to obtain non-waiver services but has no authority other than to link, refer and coordinate with other entities for such services. (g) The PCCP must be reviewed and updated by the RN case manager as frequently as necessary to ensure it continues to meet the needs of the waiver participant and family. The PCCP must be reviewed at least annually, but will be reviewed more frequently as needed based on a significant change in the participant’s condition. The review must be completed by the RN case manager during the calendar month in which it is due.

Appendix D: Participant-Centered Planning and Service Delivery

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

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

Character Count: out of 12000

RN case managers will assess for risks during the initial and reassessment home visits. Potential risks will be identified and preventative interventions and strategies will be discussed with the participant. Waiver enrolled home health agencies are responsible to send a replacement provider as a back-up if the scheduled provider is not available. The RN case managers will regularly assess the amount and frequency of services as another method of mitigating identified risks. The RN case manager will assess for and help the participant to identify informal supports available in addition to waiver and State Plan services including exploring the self-administered services option under the waiver.

Appendix D: Participant-Centered Planning and Service Delivery

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

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

Character Count: out of 6000

Participants are informed of all available waiver providers and freely select the provider of choice during each assessment and reassessment, whenever there is a change in their documented service needs, or when they have indicated they are dissatisfied with their current provider. RN case managers provide any additional information needed to support the participant to make an informed choice. Freedom of choice of available providers is documented by the participant’s signature on the PCCP.

Appendix D: Participant-Centered Planning and Service Delivery

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

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

Character Count: out of 6000

The waiver is directly managed by the Medicaid Agency.

Appendix D: Participant-Centered Planning and Service Delivery

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

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

Every three months or more frequently when necessary

Every six months or more frequently when necessary

Every twelve months or more frequently when necessary

Other schedule

Specify the other schedule:

Character Count: out of 6000
Maintenance of Service Plan Forms. Written copies or electronic facsimiles of service plans are maintained for a minimum period of 3 years as required by 45 CFR �92.42. Service plans are maintained by the following (check each that applies):

Medicaid agency

Operating agency

Case manager

Other

Specify:

Character Count: out of 4000

Appendix D: Participant-Centered Planning and Service Delivery

D-2: Service Plan Implementation and Monitoring

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

Character Count: out of 24000

The RN case managers are responsible for PCCP monitoring the implementation through periodic home visits and phone calls. In all cases, frequency of home visits will be at six month intervals at a minimum but may be conducted more frequently based on the complexity of the participant’s needs. In addition, the participant was instructed at the time of PCCP development, to contact the RN cases manager with any questions or concerns about services, coordination with other benefits or health and safety concerns. The participant will also be instructed to report hospitalizations or other incidents involving the participant. During home visits and phone calls, the RN case manager will confirm the participant is receiving services in accordance with the approved PCCP, quality services are being provided and the services are sufficient to meet the health and safety needs of the participant. These interactions provide opportunities for the RN case manager to become aware of concerns and issues. In addition, the RN case manager, home health agencies and other providers collaborate to assure services are meeting the needs of the participant. If participants want to change providers at any time, RN case managers provide information about available providers and update the PCCP to reflect the changes. Participants who receive less than one waiver service per month will be contacted by the RN case manager on a monthly basis to assess needs and risks. RN case managers assist the participant and family in solving issues and problems through phone calls, scheduling case conferences and coordinating with providers. Participants are encouraged to call the RN case manager with concerns and problems as they arise. Should issues arise with the provision of case management, the Waiver Program Manager/SMA leadership would intervene to resolve the concern. Back-up plans using informal supports and coordinating services among several providers are used to ensure access to services thereby promoting the health and safety of the individual. Care planning meetings and periodic monitoring will also include an assessment of the access and receipt of non-waiver services, including natural supports and Medicaid State plan services. RN case managers will make note of any issues or problems in the participant’s case file along with steps that will be followed to remediate or address the problems. Separate from the ongoing monitoring completed by the RN cases manager, an annual quality assurance review of a representative sample of PCCPs will be conducting by the quality assurance team within the Bureau of Authorization and Community based Services. These reviews will evaluate utilization of waiver services to assure that the PCCPs specify services by type, amount, duration, scope and frequency. A concurrent post-payment review of selected recipients’ claims is also conducted by BACBS to verify the extent in which providers delivered authorized services.

Monitoring Safeguards. Select one:

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

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

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

Character Count: out of 24000

Appendix D: Participant-Centered Planning and Service Delivery

Quality Improvement: Service Plan

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

Methods for Discovery: Service Plan Assurance/Sub-assurances

The state demonstrates it has designed and implemented an effective system for reviewing the adequacy of service plans for waiver participants.

Sub-Assurances:

Sub-assurance: Service plans address all participants� assessed needs (including health and safety risk factors) and personal goals, either by the provision of waiver services or through other means.

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.

Performance Measure:

Number and percentage of Plans of Care that address the assessed needs of recipients including health and safety risk factors, either by waiver services or through other means (Numerator=# of Plans of care that address all assessed needs; Denominator=Total # of Plans reviewed).

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:

Sub-assurance: The State monitors service plan development in accordance with its policies and procedures.

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.

Performance Measure:

Number and Percentage of PCSPs in which State Plan services and other resources, for which the individual is eligible, are exhausted prior to authorizing the same service offered through the waiver. (Numerator = # of care plans in compliance; Denominator = # of total care plans reviewed).

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:

Sub-assurance: Service plans are updated/revised at least annually or when warranted by changes in the waiver participant�s needs.

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.

Performance Measure:

Number and percentage of PCSPs reviewed and updated at least annually. (Numerator = # of care plans in compliance; Denominator = # of total care plans reviewed).

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 changes to PCSPs that were completed when warranted by changes in the participant’s needs. (Numerator = # care plan changes completed; Denominator = # of total care plans changes required).

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:

Sub-assurance: Services are delivered in accordance with the service plan, including the type, scope, amount, duration and frequency specified in the service plan.

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.

Performance Measure:

Number and percentage of recipients who received services in accordance with their Plan of Care including the type, amount, frequency and duration. (Numerator = # of plans of care where amount/frequency/duration for all waiver services was provided; Denominator = # of care plans reviewed).

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:

Sub-assurance: Participants are afforded choice: Between waiver services and institutional care; and between/among waiver services and providers.

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.

Performance Measure:

Number and percentage of recipients who are offered the choice between nursing facility care and waiver services.(Numerator = # of recipients where choice of service delivery was documented; Denominator = total # of recipients reviewed).

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 recipients who are offered choice of services and providers (when more than one is available) and is documented on a signed freedom of choice form. (Numerator = # of recipients who were offered choice of service and providers when available; Denominator = # of recipients enrolled in the waiver).

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:

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 MCCW Unit conducts an annual review of the Medically Complex Children’s Waiver program for each of the three waiver years. At a minimum, one comprehensive review involving the SMA QA Unit will be conducted during this three year cycle. The SMA QA Unit also has discretion to perform focused reviews as determined to be necessary. The criteria for the focused reviews will be determined from the SMA MCCW Unit and SMA QA Unit review findings as well as other issues that develop during the review year. The sample size for the first year review will be sufficient to provide a confidence level equal to 95%, a response distribution of 50%, and a confidence interval equal to 5. For future years, the State will request a lower response distribution based on the statistical evidence of previous reviews.

Methods for Remediation/Fixing Individual Problems

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 that affect the health and welfare of individual participants are addressed immediately. Issues that are less immediate are corrected within designated time frames and are documented through the SMA Quality Assurance final review report. When the SMA determines that an issue is resolved, notification is provided and documentation is maintained by the SMA.

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:

Timelines

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

No

Yes

not selected

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

Character Count: out of 6000

Appendix E: Participant Direction of Services

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

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

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

not selected

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

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

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

No. Independence Plus designation is not requested.

not selected

Appendix E: Participant Direction of Services

E-1: Overview (1 of 13)

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

Character Count: out of 12000

Self- directed services are those provided through a non-agency based provider. Under this method, participants hire individual employees to perform respite services. During the needs assessment and PCCP development process, the RN case manager will discuss the ability to receive services under the Self Directed method. If the participant elects to receive Self Directed services the RN case manager will provide information to the participant regarding Self Directed Service requirements and the participant’s responsibilities to manage their employees. The participant is responsible to manage the employee(s) including recruiting, hiring, providing supervision, including assuring that the employee does not perform functions outside the scope of their training or licensure, training, scheduling and assuring time sheet accuracy and submitting time sheets to the FMS provider. The Self Directed Service delivery method requires the use of Financial Management Services (FMS) to assist with managing associated employer-related financial responsibilities. During the needs assessment and PCCP development process, the RN case manager will discuss the ability to receive services under the Self Directed Service method. If the participant elects to receive Self Directed services the RN case manager will provide information to the participant regarding the associated responsibilities and requirements. At a minimum of monthly the FMS provider will send the employer and the RN case manager information at least monthly detailing the units of services used and the number of authorized units remaining.

Appendix E: Participant Direction of Services

E-1: Overview (2 of 13)

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

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

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

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

not selected
Availability of Participant Direction by Type of Living Arrangement. Check each that applies:

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

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

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

Specify these living arrangements:

Character Count: out of 4000

Appendix E: Participant Direction of Services

E-1: Overview (3 of 13)

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

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

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

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

Specify the criteria

Character Count: out of 18000

Appendix E: Participant Direction of Services

E-1: Overview (4 of 13)

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

Character Count: out of 12000

During the initial assessment process, RN case managers will review a list of available service providers and will discuss the self- directed services option. If the participant elects the self- directed services option, the RN case manager will provide training regarding the role and responsibilities involved with being an employer and the requirement for FMS to be a service that is included in the PCCP. Relative to the needs of the individual, the RN case manager will review both the skilled nursing and routine respite options and will discuss the types of tasks that must be performed by an RN versus those that can be performed. The RN case manager will provide the participant with written information detailing the respite services available through the Self Directed method and a list of enrolled FMS providers. The RN case manager will explain the option to have all or a part of their authorized services delivered through the Self Directed model and/or all or part of their services through a Medicaid enrolled licensed home health agency. The information provided during the initial assessment will enable the participant to make an informed choice about their options. This information also outlines the benefits, potential liabilities and participant responsibilities if the Self Directed Service option is chosen.

Appendix E: Participant Direction of Services

E-1: Overview (5 of 13)

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

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

The State provides for the direction of waiver services by representatives.

Specify the representatives who may direct waiver services: (check each that applies):

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

Waiver services may be directed by a non-legal representative freely chosen by an adult participant.

Specify the policies that apply regarding the direction of waiver services by participant-appointed representatives, including safeguards to ensure that the representative functions in the best interest of the participant:

Character Count: out of 12000

Appendix E: Participant Direction of Services

E-1: Overview (6 of 13)

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

Waiver Service Employer Authority Budget Authority

Skilled Nursing Respite and Routine Respite

Appendix E: Participant Direction of Services

E-1: Overview (7 of 13)

Financial Management Services. Except in certain circumstances, financial management services are mandatory and integral to participant direction. A governmental entity and/or another third-party entity must perform necessary financial transactions on behalf of the waiver participant. Select one:

Yes. Financial Management Services are furnished through a third party entity. (Complete item E-1-i).

Specify whether governmental and/or private entities furnish these services. Check each that applies:

Governmental entities

Private entities

No. Financial Management Services are not furnished. Standard Medicaid payment mechanisms are used. Do not complete Item E-1-i.

not selected

Appendix E: Participant Direction of Services

E-1: Overview (8 of 13)

Appendix E: Participant Direction of Services

E-1: Overview (9 of 13)

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

Case Management Activity. Information and assistance in support of participant direction are furnished as an element of Medicaid case management services.

Specify in detail the information and assistance that are furnished through case management for each participant direction opportunity under the waiver:

Character Count: out of 6000

During the initial assessment process, RN case managers will review a list of available service providers and will discuss the self- directed services option. If the participant elects the self- directed services option, the RN case manager will provide training regarding the role and responsibilities involved with being an employer and the requirement for FMS to be a service that is included in the PCCP. Relative to the needs of the individual, the RN case manager will review both the skilled nursing and routine respite options and will discuss the types of tasks that must be performed by an RN versus those that can be performed. The RN case manager will provide the participant with written information detailing the respite services available through the Self Directed Services method and a list of enrolled FMS providers. The RN case manager will explain the option to have all or a part of their authorized services delivered through the Self Directed Services model and/or all or part of their services through a Medicaid enrolled licensed home health agency. The information provided during the initial assessment will enable the participant to make an informed choice about their options. This information also outlines the benefits, potential liabilities and participant responsibilities if the Self Directed Services option is chosen.

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

Financial Management Services

Skilled Nursing Respite and Routine Respite

Administrative Activity. Information and assistance in support of participant direction are furnished as an administrative activity.

Specify (a) the types of entities that furnish these supports; (b) how the supports are procured and compensated; (c) describe in detail the supports that are furnished for each participant direction opportunity under the waiver; (d) the methods and frequency of assessing the performance of the entities that furnish these supports; and, (e) the entity or entities responsible for assessing performance:

Character Count: out of 12000

Appendix E: Participant Direction of Services

E-1: Overview (10 of 13)

Independent Advocacy (select one).

No. Arrangements have not been made for independent advocacy.

Yes. Independent advocacy is available to participants who direct their services.

Describe the nature of this independent advocacy and how participants may access this advocacy:

Character Count: out of 12000

Appendix E: Participant Direction of Services

E-1: Overview (11 of 13)

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

Character Count: out of 12000

If the participant voluntarily terminates self- directed services, the RN case manager will re-evaluate the participant’s service needs and assist the participant to select an agency based service provider. The transition to a new provider will include all aspects of the PCCP development including timeliness and the choice of willing and available providers. Health and safety and continuity of services will be assured during the transition.

Appendix E: Participant Direction of Services

E-1: Overview (12 of 13)

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

Character Count: out of 12000

Only after a participant has repeatedly demonstrated an incapacity for self- directed or problems with fraud or malfeasance have been identified would involuntary termination of self- directed services occur. Prior to that occurrence however, the RN case manager will offer participants who are struggling with self- directed services repeated assistance and consultation to assist the participant to acquire the skills necessary to be successful. Only after the failure of all these efforts will the State involuntarily terminate self- directed services for a participant. The transition to agency-based care will include all aspects of PCCP development including input from the participant on service needs, the assurance of health and welfare during the transition and the choice among willing and available providers. During the transition to agency-based care, self- directed services may continue (as long as the participant's health and welfare is assured) until a home health agency has been identified and waiver services initiated. If a case of fraud or misuse of funds, is suspected, immediate termination of self-directed services is allowed. In this case, the RN case manager would be responsible for obtaining an emergency provider of waiver services.

Appendix E: Participant Direction of Services

E-1: Overview (13 of 13)

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

Table E-1-n
	Employer Authority Only	Budget Authority Only or Budget Authority in Combination with Employer Authority
Waiver Year	Number of Participants	Number of Participants
Year 1
Year 2
Year 3

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant Direction (1 of 6)

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (2 of 6)

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (3 of 6)

Participant - Budget Authority

Answers provided in Appendix E-1-b indicate that you do not need to complete this section.
1. Participant-Directed Budget Describe in detail the method(s) that are used to establish the amount of the participant-directed budget for waiver goods and services over which the participant has authority, including how the method makes use of reliable cost estimating information and is applied consistently to each participant. Information about these method(s) must be made publicly available.
  
  Character Count: out of 12000

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (4 of 6)

Participant - Budget Authority

Answers provided in Appendix E-1-b indicate that you do not need to complete this section.
1. Informing Participant of Budget Amount. Describe how the State informs each participant of the amount of the participant-directed budget and the procedures by which the participant may request an adjustment in the budget amount.
  
  Character Count: out of 12000

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (5 of 6)

Participant - Budget Authority

Answers provided in Appendix E-1-b indicate that you do not need to complete this section.

Participant Exercise of Budget Flexibility. Select one:

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

The participant has the authority to modify the services included in the participant directed budget without prior approval.

Specify how changes in the participant-directed budget are documented, including updating the service plan. When prior review of changes is required in certain circumstances, describe the circumstances and specify the entity that reviews the proposed change:

Character Count: out of 12000

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (6 of 6)

Participant - Budget Authority

Answers provided in Appendix E-1-b indicate that you do not need to complete this section.
1. Expenditure Safeguards. Describe the safeguards that have been established for the timely prevention of the premature depletion of the participant-directed budget or to address potential service delivery problems that may be associated with budget underutilization and the entity (or entities) responsible for implementing these safeguards:
  
  Character Count: out of 12000

Appendix F: Participant Rights

Appendix F-1: Opportunity to Request a Fair Hearing

The State provides an opportunity to request a Fair Hearing under 42 CFR Part 431, Subpart E to individuals: (a) who are not given the choice of home and community-based services as an alternative to the institutional care specified in Item 1-F of the request; (b) are denied the service(s) of their choice or the provider(s) of their choice; or, (c) whose services are denied, suspended, reduced or terminated. The State provides notice of action as required in 42 CFR �431.210.

Procedures for Offering Opportunity to Request a Fair Hearing. Describe how the individual (or his/her legal representative) is informed of the opportunity to request a fair hearing under 42 CFR Part 431, Subpart E. Specify the notice(s) that are used to offer individuals the opportunity to request a Fair Hearing. State laws, regulations, policies and notices referenced in the description are available to CMS upon request through the operating or Medicaid agency.

Character Count: out of 12000

An applicant/participant will not be offered waiver services if the assessment indicates he/she cannot adequately/safely be served in the community and will be given written notice of rights to a fair hearing.

The participant will be offered the choice of waiver services only if the individual's needs can be met appropriately in the community with waiver and other available State Plan services and the preliminary PCCP has been agreed to by all parties.

If waiver services are chosen, the participant will also be given the opportunity to choose an available provider of waiver service(s) if more than one qualified provider is available to render the service(s).

Upon entrance to the waiver program, the participant will be informed verbally and in writing by the RN case manager during the initial home visit of:

a)	the feasible alternatives available under the waiver;
b)	their right to choose institutional care or home and community based care; and
c)	the Medicaid complaint, grievance and fair hearing process. 

A form signed by the participant will be maintained in the recipient's case record to document their awareness of rights to a fair hearing upon entrance to the waiver.

Documentation will also be maintained in the recipient file concerning the choices given and the response to those choices.  

It is the policy of BACBS to resolve disputes at the lowest level.  The following is not meant to foreclose the State’s preference for informal resolutions through open discussion and negotiation between the State, applicants, recipients, providers and all other interested parties.

In addition to any and all hearing rights detailed in UAC 410-14, eligible waiver applicants/participants will be given an opportunity for a hearing, upon written request, if the participant:

1.	Is not offered the choice of nursing facility care or community-based (waiver) services;
2.	The scope, frequency and/or duration of waiver services are reduced/suspended or terminated; 
3.	Is denied the waiver services of their choice; or
4.	Is denied the waiver provider(s) of their choice if more than one provider is available to render the service(s).

Notices of adverse actions are given to individuals verbally and followed-up with a formal written notice of agency action.  Included in the formal written notice are specified timeframes for filing an appeal and informing participants that services may continue during the appeal process.  However, if as a result of the hearing, the action taken by the State Medicaid Agency is found to be correct, the participant will be responsible to pay the costs of the services provided during the appeal period.  Content of the notices conforms to 42 CFR 431.  Documentation of these notices is maintained in the participant’s case file.

Appendix F: Participant-Rights

Appendix F-2: Additional Dispute Resolution Process

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

No. This Appendix does not apply

Yes. The State operates an additional dispute resolution process

not selected
Description of Additional Dispute Resolution Process. Describe the additional dispute resolution process, including: (a) the State agency that operates the process; (b) the nature of the process (i.e., procedures and timeframes), including the types of disputes addressed through the process; and, (c) how the right to a Medicaid Fair Hearing is preserved when a participant elects to make use of the process: State laws, regulations, and policies referenced in the description are available to CMS upon request through the operating or Medicaid agency.

Character Count: out of 12000

Appendix F: Participant-Rights

Appendix F-3: State Grievance/Complaint System

Operation of Grievance/Complaint System. Select one:

No. This Appendix does not apply

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

not selected
Operational Responsibility. Specify the State agency that is responsible for the operation of the grievance/complaint system:

Character Count: out of 4000

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

Character Count: out of 12000

The State Medicaid Agency operates an internal complaint/grievance system. The Medicaid constituent services’ representative receives complaints from participants, providers, family or other community or stakeholder groups. The individual lodging the complaint is informed by the constituent services representative that filing a grievance or making a complaint is not a prerequisite or substitute for a formal hearing. a) Types of complaints received may include but are not limited to, the availability of services, provider staff complaints, quality of care, eligibility problems, claims payment problems, policy clarification requests, requests for additional coverage or information about what is covered by the MCCW and other Medicaid program issues. b) The complaints are documented in the Medicaid Managed Care System (MMCS) and assigned a tracking number. Data entered includes the client name and type of complaint they are filing. Details about the situation are documented in the system in a narrative format and steps to resolution are then entered on the case. Medicaid agency managers are notified via monthly reports generated electronically through the MMCS system regarding any resolution efforts that have been or need to be taken by the constituent services’ representative and documented in the electronic case record. Time frames for addressing complaints are determined by the source, i.e. Governor's office or Director's office, or by urgency of call. Most calls are resolved with 10 days. c) If the complaint/grievance is not resolved at the constituent service level the waiver participant will be advised by the constituent services representative of the need to file a request for a fair hearing within the allowed time limits. The informal dispute resolution process will continue during the interim period until the fair hearing is scheduled and conducted. Federal and state laws set forth for the Medicaid program are followed for resolution of claims payment, coverage and eligibility issues. Medicaid policy, found in provider manuals and the Medicaid eligibility manual, is referenced for policy and eligibility problems and service issues. If the complaint involved civil rights or discrimination situations, the participant would be referred to the Regional Civil Rights Office to be reported in writing. The Medicaid Member Guide informs the participant of their right to contact the Medicaid constituent services line to discuss issues or concerns. Additionally, the RN case managers provide written materials to the participant with grievances or complaints contact information. Contacts include the names and numbers of the specific RN case manager and the State Medicaid Agency’s constituent services representative.

Appendix G: Participant Safeguards

Appendix G-1: Response to Critical Events or Incidents

Critical Event or Incident Reporting and Management Process. Indicate whether the State operates Critical Event or Incident Reporting and Management Process that enables the State to collect information on sentinel events occurring in the waiver program.Select one:

not selected

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

No. This Appendix does not apply (do not complete Items b through e)

If the State does not operate a Critical Event or Incident Reporting and Management Process, describe the process that the State uses to elicit information on the health and welfare of individuals served through the program.

Character Count: out of 12000
State Critical Event or Incident Reporting Requirements. Specify the types of critical events or incidents (including alleged abuse, neglect and exploitation) that the State requires to be reported for review and follow-up action by an appropriate authority, the individuals and/or entities that are required to report such events and incidents and the timelines for reporting. State laws, regulations, and policies that are referenced are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Character Count: out of 24000

In accordance with UCA 62-A-4a-403 Part 4 and 62-A-3-305, professionals and the public are required to report instances of abuse, neglect and exploitation. RN case managers and providers, shall immediately refer incidences of suspected abuse, neglect and exploitation to the nearest law enforcement agency, Child Protective Services (CPS) within the Division of Child and Family Services (DCFS) or Adult Protective Services (APS) within the Division of Aging and Adult Services (DAAS) for investigation. Additionally, Bureau of Authorization and Community Based Services requires the participant to notify the RN case manager by phone, email or fax within 24 hours of the occurrence of all critical incidents. Depending on the nature/severity of the critical incident, the RN case manager may investigate and remediate the incident internally or forward to the Bureau of Authorization and Community Based Services for investigation/remediation. In addition, the RN case manager must document the details of the incident on a Critical Incident Investigation form. For incidents meeting the criteria of a level one incident, the Critical Incident Investigation form must also be submitted to the Bureau of Authorization and Community Based Services within ten business days of the report of the incident. Bureau of Authorization and Community Based Services provides final oversight of the investigations of all critical incidents. The following list of the incidents/events (incidents) must be reported by the MCCW Operations Team to the MCCW QA Unit. This is not an all-inclusive list. Other incidents that rise to a comparable level must be reported to the QA Unit. 1. Abuse/Neglect (Either Alleged or Substantiated) Incidents of abuse or neglect, that resulted in the participant’s admission to a hospital. 2. Attempted Suicides Suicide attempts that resulted in the participant’s admission to a hospital. 3. Human Rights Violations Human rights violations such as the unauthorized use of restraints (physical, mechanical or chemical), seclusion rooms or infringement of personal privacy rights experienced by the participant. (Infringement of personal privacy rights is defined as an unwanted restriction imposed upon the participant.) Reporting is not required for Emergency Behavioral Interventions as defined in R539-4-6. 4. Incidents Involving the Media or Referred by Elected Officials Incidents that have or are anticipated to receive public attention (i.e. events covered in the media or referred by the Governor, legislators or other elected officials). 5. Medication Errors Errors relating to a participant’s medication that resulted in the participant’s admission to a hospital. 6. Missing Persons For reporting purposes, the following participants are considered to be missing: a. Participants who have been missing for at least twenty-four hours; or b. Regardless of the number of hours missing – any participant who is missing under unexplained, involuntary or suspicious circumstances and is believed to be in danger because of age, health, mental or physical disability, environment or weather or who could be in the company of a potentially dangerous person or some other factor that places the participant in peril. 7. Unexpected Deaths All deaths are considered unexpected with the exception of: a. Participants receiving hospice care; and/or b. Deaths due to natural causes, general system failure or terminal/chronic health conditions. 8. Unexpected Hospitalization Serious burns, self injurious behavior or injuries resulting in loss of physical or mental function such as a loss of limb, paralysis, brain injury or memory loss experienced by a participant that resulted in admission to a hospital for medical treatment. 9. Waste, Fraud or Abuse of Medicaid Funds Incidents that involve alleged or confirmed waste, fraud or abuse of Medicaid funds by either a provider or a recipient of Medicaid services. The following incidents must be reported by providers, participants and/or their representatives to the MCCW Operations Unit, but are not required to be reported to the QA Unit. This is not an all-inclusive list. Other incidents that rise to a comparable level must be reported to the MCCW Operations Unit. 1. Abuse/Neglect/Exploitation (Either Alleged or Substantiated) a. Incidents of abuse or neglect, that resulted in medical treatment at a medical clinic or emergency room. b. Exploitation of participant’s funds. 2. Attempted Suicides Suicide attempts that did not result in the participant being admitted to a hospital. 3. Compromised Working or Living Environment An event in which the participant’s working or living environment (e.g. roof collapse, fire, etc.) is compromised and the participant(s) require(s) evacuation. 4. Law Enforcement Involvement Activities perpetrated by the participant resulting in charges filed by law enforcement. For this category, the date of the incident will be recorded as the date on which the filing of charges occurred. 5. Medication Errors Errors relating to a participant’s medication which result in the participant experiencing adverse side effects requiring medical treatment at a medical clinic or emergency room. 6. Unexpected Hospitalization Injuries, aspiration or choking experienced by participants that resulted in admission to a hospital. (These do not include serious burns, self-injurious behavior or injuries resulting in loss of physical or mental function such as a loss of limb, paralysis, brain injury or memory loss experienced by a participant that resulted in admission to a hospital for medical treatment which is reportable to the QA Unit).
Participant Training and Education. Describe how training and/or information is provided to participants (and/or families or legal representatives, as appropriate) concerning protections from abuse, neglect, and exploitation, including how participants (and/or families or legal representatives, as appropriate) can notify appropriate authorities or entities when the participant may have experienced abuse, neglect or exploitation.

Character Count: out of 12000

Upon enrollment and annually thereafter, RN case managers will provide information to participants related to laws and protections from abuse, neglect and exploitation. Under UCA 62-A-4a-403 Part 4 Child Abuse or Neglect Reporting Requirements and 62-A-3-305, Adult Reporting Requirements, professionals and the public are required to report instances of abuse, neglect and exploitation. In addition, the RN case manager will offer information and instruct participants tatives on the following topics: a) how to avoid theft/security issues; b) maintaining personal safety when recruiting/interviewing potential employees; c) assertiveness/boundaries/rules with employees; d) maintaining personal safety when firing an employee; e) when and how to report instances of abuse, neglect or exploitation; and f) resources in their community to assist victims of abuse, neglect or exploitation.
Responsibility for Review of and Response to Critical Events or Incidents. Specify the entity (or entities) that receives reports of critical events or incidents specified in item G-1-a, the methods that are employed to evaluate such reports, and the processes and time-frames for responding to critical events or incidents, including conducting investigations.

Character Count: out of 12000

The Bureau of Authorization and Community Based Services is the entity that receives reports of level one incidents. Within ten days of reporting these types of incidents to Bureau of Authorization and Community Based Services, the RN case manager will investigate the incident and submit the Critical Incident Investigation document on which the details of the incident are recorded. Cases that are complicated and involve considerable investigation may require additional time to complete the Critical Incident Investigation document. The Bureau of Authorization and Community Based Services then reviews the Critical Incident Investigation document to determine if the incident could have been avoided, if additional supports or interventions have been implemented to prevent the incident from recurring, if changes to the PCCP have been made, if any systemic issues were identified and a plan to address systemic issues developed. The Bureau of Authorization and Community Based Services then completes its portion of the Critical Incident Investigation document which includes a summary of the incident, remediation activities and findings and recommendations. At the conclusion of the investigation, participants are informed in writing of the investigation results within two weeks of the closure of the case by the Bureau of Authorization and Community Based Services when appropriate to the nature of the incident.
Responsibility for Oversight of Critical Incidents and Events. Identify the State agency (or agencies) responsible for overseeing the reporting of and response to critical incidents or events that affect waiver participants, how this oversight is conducted, and how frequently.

Character Count: out of 12000

The Bureau of Authorization and Community Based Services is the entity responsible for overseeing the reporting and response to level one critical incidents that affect waiver recipients. Information about critical incidents is collected in the Bureau of Authorization and Community Based Services critical incident database. This information is analyzed and an annual report is submitted to the State Medicaid Director which describes the number of incidents by category, number of incidents that resulted in corrective action by the RN case managers or the provider, number of corrective actions that were implemented and a summary analysis of systemic trends that required additional intervention or process improvement steps.

Appendix G: Participant Safeguards

Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (1 of 3)

Use of Restraints. (Select one): (For waiver actions submitted before March 2014, responses in Appendix G-2-a will display information for both restraints and seclusion. For most waiver actions submitted after March 2014, responses regarding seclusion appear in Appendix G-2-c.)

The State does not permit or prohibits the use of restraints

Specify the State agency (or agencies) responsible for detecting the unauthorized use of restraints and how this oversight is conducted and its frequency:

Character Count: out of 12000

The Divisions of Child and Family Services and Adult and Aging Services receive referrals from professionals and the public when use of restraints is suspected. The BACBS quality assurance team monitors for the use of any restraints during annual formal reviews. BACBS reviews participant records and conducts interviews with participants to identify the use of restraints or seclusion. The RN case manager is also responsible for ongoing monitoring of the participants’ health and welfare including ensuring that restraints are not utilized. This is accomplished through home visits and telephone contacts with the participant and providers. Face to face visits with recipients occur at a minimum of every six months.

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

not selected
1. Safeguards Concerning the Use of Restraints. Specify the safeguards that the State has established concerning the use of each type of restraint (i.e., personal restraints, drugs used as restraints, mechanical restraints). State laws, regulations, and policies that are referenced are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
  
  Character Count: out of 12000
2. State Oversight Responsibility. Specify the State agency (or agencies) responsible for overseeing the use of restraints and ensuring that State safeguards concerning their use are followed and how such oversight is conducted and its frequency:
  
  Character Count: out of 12000

Appendix G: Participant Safeguards

Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (2 of 3)

Use of Restrictive Interventions. (Select one):

The State does not permit or prohibits the use of restrictive interventions

Specify the State agency (or agencies) responsible for detecting the unauthorized use of restrictive interventions and how this oversight is conducted and its frequency:

Character Count: out of 12000

The Divisions of Child and Family Services and Adult and Aging Services receive referrals from professionals and the public when use of restrictive interventions is suspected. The BACBS quality assurance team monitors for the use of any restrictive interventions during annual formal reviews. BACBS reviews participant records and conducts interviews with participants to identify the use of restrictive interventions. The RN case manager is responsible for ongoing monitoring of the participants’ health and welfare including ensuring that restrictive interventions are not utilized. This is accomplished through home visits and telephone contacts with the participant and providers. Face to face visits with participants occur at a minimum of every six months.

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

not selected
1. Safeguards Concerning the Use of Restrictive Interventions. Specify the safeguards that the State has in effect concerning the use of interventions that restrict participant movement, participant access to other individuals, locations or activities, restrict participant rights or employ aversive methods (not including restraints or seclusion) to modify behavior. State laws, regulations, and policies referenced in the specification are available to CMS upon request through the Medicaid agency or the operating agency.
  
  Character Count: out of 20000
2. State Oversight Responsibility. Specify the State agency (or agencies) responsible for monitoring and overseeing the use of restrictive interventions and how this oversight is conducted and its frequency:
  
  Character Count: out of 20000

Appendix G: Participant Safeguards

Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (3 of 3)

Use of Seclusion. (Select one): (This section will be blank for waivers submitted before Appendix G-2-c was added to WMS in March 2014, and responses for seclusion will display in Appendix G-2-a combined with information on restraints.)

The State does not permit or prohibits the use of seclusion

Specify the State agency (or agencies) responsible for detecting the unauthorized use of seclusion and how this oversight is conducted and its frequency:

Character Count: out of 12000

The Divisions of Child and Family Services and Adult and Aging Services receive referrals from professionals and the public when use of seclusion is suspected. The BACBS quality assurance team monitors for the use of seclusion during annual formal reviews. BACBS reviews participant records and conducts interviews with participants to identify the use of seclusion. The RN case manager is responsible for ongoing monitoring of the participants’ health and welfare including ensuring that seclusion is not utilized. This is accomplished through home visits and telephone contacts with the participant and providers. Face to face visits with participants occur at a minimum of every six months.

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

not selected
1. Safeguards Concerning the Use of Seclusion. Specify the safeguards that the State has established concerning the use of each type of seclusion. State laws, regulations, and policies that are referenced are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
  
  Character Count: out of 12000
2. State Oversight Responsibility. Specify the State agency (or agencies) responsible for overseeing the use of seclusion and ensuring that State safeguards concerning their use are followed and how such oversight is conducted and its frequency:
  
  Character Count: out of 12000

Appendix G: Participant Safeguards

Appendix G-3: Medication Management and Administration (1 of 2)

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

Applicability. Select one:

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

Yes. This Appendix applies (complete the remaining items)

not selected
Medication Management and Follow-Up
1. Responsibility. Specify the entity (or entities) that have ongoing responsibility for monitoring participant medication regimens, the methods for conducting monitoring, and the frequency of monitoring.
  
  Character Count: out of 12000
2. Methods of State Oversight and Follow-Up. Describe: (a) the method(s) that the State uses to ensure that participant medications are managed appropriately, including: (a) the identification of potentially harmful practices (e.g., the concurrent use of contraindicated medications); (b) the method(s) for following up on potentially harmful practices; and, (c) the State agency (or agencies) that is responsible for follow-up and oversight.
  
  Character Count: out of 12000

Appendix G: Participant Safeguards

Appendix G-3: Medication Management and Administration (2 of 2)

Medication Administration by Waiver Providers

Answers provided in G-3-a indicate you do not need to complete this section
1. Provider Administration of Medications. Select one:
  
  Not applicable. (do not complete the remaining items)
  
  Waiver providers are responsible for the administration of medications to waiver participants who cannot self-administer and/or have responsibility to oversee participant self-administration of medications. (complete the remaining items)
  
  not selected
2. State Policy. Summarize the State policies that apply to the administration of medications by waiver providers or waiver provider responsibilities when participants self-administer medications, including (if applicable) policies concerning medication administration by non-medical waiver provider personnel. State laws, regulations, and policies referenced in the specification are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
  
  Character Count: out of 12000
3. Medication Error Reporting. Select one of the following:
  
  Providers that are responsible for medication administration are required to both record and report medication errors to a State agency (or agencies).
  
  Complete the following three items:
  
  (a) Specify State agency (or agencies) to which errors are reported:
  
  Character Count: out of 12000
  
  (b) Specify the types of medication errors that providers are required to record:
  
  Character Count: out of 12000
  
  (c) Specify the types of medication errors that providers must report to the State:
  
  Character Count: out of 12000
  
  Providers responsible for medication administration are required to record medication errors but make information about medication errors available only when requested by the State.
  
  Specify the types of medication errors that providers are required to record:
  
  Character Count: out of 12000
  
  not selected
4. State Oversight Responsibility. Specify the State agency (or agencies) responsible for monitoring the performance of waiver providers in the administration of medications to waiver participants and how monitoring is performed and its frequency.
  
  Character Count: out of 12000

Appendix G: Participant Safeguards

Quality Improvement: Health and Welfare

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

Methods for Discovery: Health and Welfare

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

Sub-Assurances:

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

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.

Performance Measure:

Number and percentage of suspected abuse, neglect or exploitation incidents referred to Child Protective Services and/or law enforcement as required by State law. (Numerator = # of referrals made; Denominator = total # of referrals required).

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 participant deaths which are reviewed to determine if they unexplained and require further investigation. (Numerator = # of participant deaths reviewed; Denominator = # of total participant deaths during the review period).

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:

Sub-assurance: The state demonstrates that an incident management system is in place that effectively resolves those incidents and prevents further similar incidents to the extent possible.

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.

Performance Measure:

Number and percentage of incidents/events that met the SMA critical incident criteria which were reported to the SMA QA Unit. (Numerator = # of incidents in compliance; Denominator = total # of reportable incidents).

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 incidents for which prevention strategies were developed and implemented when warranted. (Numerator = # of incidents with prevention developed and implemented;Denominator = total # of reportable incidents).

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:

Sub-assurance: The state policies and procedures for the use or prohibition of restrictive interventions (including restraints and seclusion) are followed.

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.

Performance Measure:

Number and Percentage of incidents involving restrictive interventions (including restraints & seclusion) that are reported and investigated. (Numerator = # of incidents investigated; Denominator = # of incidents identified requiring review).

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:

Sub-assurance: The state establishes overall health care standards and monitors those standards based on the responsibility of the service provider as stated in the approved waiver.

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.

Performance Measure:

Number and percentage of quarterly nursing home assessments completed by RN Case Managers. (Numerator = # of recipients where all required assessments were completed; Denominator = # of recipients reviewed).

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 recipients’ legal representatives/families that were educated on, and provided with, information on medical homes. (Numerator = # of recipients provided with information; Denominator = total # of recipients reviewed).

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 recipients’ legal representatives/families that indicated they were satisfied with their medical and waiver providers or understood how to report healthcare/service concerns. (Numerator = # of recipients provided with information; Denominator = total # of recipients reviewed).

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:

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 MCCW Unit conducts an annual review of the Medically Complex Children’s Waiver program for each of the three waiver years. At a minimum, one comprehensive review involving the SMA QA Unit will be conducted during this three year cycle. The SMA QA Unit also has discretion to perform focused reviews as determined to be necessary. The criteria for the focused reviews will be determined from the SMA MCCW Unit and SMA QA Unit review findings as well as other issues that develop during the review year. The sample size for the first year review will be sufficient to provide a confidence level equal to 95%, a response distribution of 50%, and a confidence interval equal to 5. For future years, the State will request a lower response distribution based on the statistical evidence of previous reviews.

Methods for Remediation/Fixing Individual Problems

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 that affect the health and welfare of individual participants are addressed immediately. Issues that are less immediate are corrected within designated time frames and are documented through the SMA Quality Assurance final review report. When the SMA determines that an issue is resolved, notification is provided and documentation is maintained by the SMA.

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:

Timelines

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

No

Yes

not selected

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

Character Count: out of 6000

Appendix H: Quality Improvement Strategy (1 of 2)

Under �1915(c) of the Social Security Act and 42 CFR �441.302, the approval of an HCBS waiver requires that CMS determine that the State has made satisfactory assurances concerning the protection of participant health and welfare, financial accountability and other elements of waiver operations. Renewal of an existing waiver is contingent upon review by CMS and a finding by CMS that the assurances have been met. By completing the HCBS waiver application, the State specifies how it has designed the waiver’s critical processes, structures and operational features in order to meet these assurances.

Quality Improvement is a critical operational feature that an organization employs to continually determine whether it operates in accordance with the approved design of its program, meets statutory and regulatory assurances and requirements, achieves desired outcomes, and identifies opportunities for improvement.

CMS recognizes that a state’s waiver Quality Improvement Strategy may vary depending on the nature of the waiver target population, the services offered, and the waiver’s relationship to other public programs, and will extend beyond regulatory requirements. However, for the purpose of this application, the State is expected to have, at the minimum, systems in place to measure and improve its own performance in meeting six specific waiver assurances and requirements.

It may be more efficient and effective for a Quality Improvement Strategy to span multiple waivers and other long-term care services. CMS recognizes the value of this approach and will ask the state to identify other waiver programs and long-term care services that are addressed in the Quality Improvement Strategy.

Quality Improvement Strategy: Minimum Components

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

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

The evidence based discovery activities that will be conducted for each of the six major waiver assurances;
The remediation activities followed to correct individual problems identified in the implementation of each of the assurances;

In Appendix H of the application, a State describes (1) the system improvement activities followed in response to aggregated, analyzed discovery and remediation information collected on each of the assurances; (2) the correspondent roles/responsibilities of those conducting assessing and prioritizing improving system corrections and improvements; and (3) the processes the state will follow to continuously assess the effectiveness of the OIS and revise it as necessary and appropriate.

If the State's Quality Improvement Strategy is not fully developed at the time the waiver application is submitted, the state may provide a work plan to fully develop its Quality Improvement Strategy, including the specific tasks the State plans to undertake during the period the waiver is in effect, the major milestones associated with these tasks, and the entity (or entities) responsible for the completion of these tasks.

When the Quality Improvement Strategy spans more than one waiver and/or other types of long-term care services under the Medicaid State plan, specify the control numbers for the other waiver programs and/or identify the other long-term services that are addressed in the Quality Improvement Strategy. In instances when the QIS spans more than one waiver, the State must be able to stratify information that is related to each approved waiver program. Unless the State has requested and received approval from CMS for the consolidation of multiple waivers for the purpose of reporting, then the State must stratify information that is related to each approved waiver program, i.e., employ a representative sample for each waiver.

Appendix H: Quality Improvement Strategy (2 of 2)

H-1: Systems Improvement

System Improvements

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

Character Count: out of 12000

Trending is accomplished as part of the SMA annual waiver review for each performance measure that is assessed that year. Graphs display the percentage of how well the performance measures are met for each fiscal year. Graphs from the previous years are presented side by side with the current year’s results, thus allowing for tracking and trending of performance measures. After a three-year cycle of reviews (and annually thereafter),the performance measures will be analyzed to determine if, over time, a negative trend has occurred and if a systems improvement will address the problem. System improvement initiatives may be prioritized based on several factors including the health and welfare of participants, financial considerations, the intensity of the problem and the other performance measures relating to assurance being evaluated.

System Improvement Activities

Responsible Party(check each that applies):	Frequency of Monitoring and Analysis(check each that applies):
State Medicaid Agency	Weekly
Operating Agency	Monthly
Sub-State Entity	Quarterly
Quality Improvement Committee	Annually
Other Specify:	Other Specify: Third year of waiver operation

System Design Changes
1. Describe the process for monitoring and analyzing the effectiveness of system design changes. Include a description of the various roles and responsibilities involved in the processes for monitoring & assessing system design changes. If applicable, include the State's targeted standards for systems improvement.
  
  Character Count: out of 12000
  
  The SMA will establish a Quality Improvement Committee consisting of the SMA QA Unit, the SMA MCCW Unit, and others. The team will meet to assess the results of the systems design changes. The success of the systems changes will be based on criteria that must be met to determine that the change has been accomplished and also criteria that will determine that the systems change has been sustained or will be sustained. The Quality Improvement Committee will determine the sustainability criteria. Results of system design changes will be communicated to participants and families, providers, agencies and others through the Medicaid Information Bulletin and the MCCW website.
2. Describe the process to periodically evaluate, as appropriate, the Quality Improvement Strategy.
  
  Character Count: out of 12000
  
  The Quality Improvement Strategy is a dynamic document that is continuously evaluated each year by the SMA’s quality management team. The team evaluates the data collection process and makes changes as necessary to allow for accurate data collection and analysis. In addition the Quality Improvement Committee will evaluate the QIS after the third year of the waiver operation. This committee will meet to discuss the elements of the QIS for each assurance, the findings relative to each performance measure and the contributions of all parties that conduct quality assurance of the MCCW. Improvements to the QIS will be made at this time and submitted in the following waiver renewal application.

Appendix I: Financial Accountability

I-1: Financial Integrity and Accountability

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

Character Count: out of 12000

BACBS, operating within the State Medicaid Agency, assures financial accountability for funds expended for home and community-based services, and will maintain and make available financial records documenting the cost of services provided under the waiver.  Financial oversight of the waiver program begins with system edits in the Medicaid Management Information System (MMIS) to prevent payment:
	
	1)	to non-waiver enrolled providers;
	2)	to non-waiver eligible recipients;
	3)	with inappropriate coding; 
	4)	for claims billed in excess of maximum fee schedule rates; and
	5)	for overlapping/duplicative dates of service.  
	
	BACBS also conducts post-payment reviews and focused reviews of claims as part of its waiver compliance review to verify whether paid claims were: 
	
	1)	rendered to a waiver recipient;
	2)	included in the recipient’s Plan of Care;
	3)	properly billed by a qualified waiver provider; and 
	4)	claimed in accordance with Plan of Care limitations.
	
	The State conducts a single audit in conformance with the Single Audit Act.  The Office of the Utah State Auditor performs this audit.  The SMA will assure financial accountability for funds expended for home and community-based services, provide for an independent audit of its waiver program (except as CMS may otherwise specify for particular waivers), and it will maintain and make available to HHS, the Comptroller General, or other designees, appropriate financial records documenting the cost of services provided under the waiver, including reports of any independent audits conducted.

Sampling methodologies for financial reviews will conform with CMS requirements. Currently, representative samples with a 95% Confidence Interval, 5% Margin of Error and 50% Response Distribution will be used. 

Reviews may be on-site or desk reviews.  Several criteria may be used in determining whether an on-site review is more/less appropriate than a desk audit; there is not a set threshold. These criteria may include considerations such as: access to records; availability of State staff; nature of the audit (routine evaluation or response to an acute concern); whether the scope of the audit lends itself well to either on-site/desk audits; etc.

For routine audits, the State would intend to provide 30 days advance notice and work to ensure provider staff would be available. If responding to an acute concern, the State may prefer to make an unannounced visit, allowing a reasonable time-frame for the provision of records.

For individuals receiving self-directed services, when reviews of the FMS agencies are conducted, time sheeting and supporting documents are validated against submitted claims. For individuals receiving agency-based services, the case manager contacts the client on a monthly basis to assure waiver services are being delivered in accordance with the developed care plan.  During the review of FMS agencies, the SMA will review a 10% sample of all waiver participants served by that FMS agency. This review will be conducted annually by the SMA.

Review results, including findings of services provided that were not included on the care plan, are communicated to providers through a draft report of findings.  The provider is then given an opportunity to supply evidence to refute the findings cited. Should evidence be supplied, it is considered by the State prior to a final report being completed. If evidence is not produced, funds for claims paid for services not listed on the support plan are recovered.

When claims have been identified to have been paid in error, the State allows the provider to either pay the amount to be recouped in a lump-sum, or will withhold payment on future claims. Regardless which method is used, the claims identified are reversed and the FFP amount returned. 

Any cases of suspected fraud/waste or abuse of Medicaid funds are referred to the OIG for additional investigation. Payments to providers may be suspended during this process. 

Should a plan of correction be required by the provider, it is reviewed and approved prior to being implemented. During subsequent reviews, verification of items within the plan are reviewed. Should non-compliance continue, an expanded review may be completed, or a more aggressive plan may be required with more frequent reviews.  A corrective action plan would include expectations for improvement by either the next monitoring cycle, or by a date established between the SMA and provider.

The review of staffing records and qualifications will be completed during provider audits by either the SMA or the Department of Health’s licensing division. The provider qualification criteria as listed in Appendix C will be reviewed for the worker in question. Any deficiencies would be communicated with the provider, allowing an opportunity to refute findings/supply additional evidence.

Appendix I: Financial Accountability

Quality Improvement: Financial Accountability

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

Methods for Discovery: Financial Accountability

State financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver. (For waiver actions submitted before June 1, 2014, this assurance read "State financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver.")

Sub-Assurances:

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

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.

Performance Measure:

Number and percentage of paid claims which verify that services were rendered to a waiver recipient using approved waiver codes and rates. (Numerator = # of claims in compliance; Denominator = total # of paid claims).

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 paid claims that were authorized and did not exceed the amounts documented in the recipient’s Plan of Care. (Numerator = # of claims in compliance; Denominator = total # of claims paid).

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:

Sub-assurance: The state provides evidence that rates remain consistent with the approved rate methodology throughout the five year waiver cycle.

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.

Performance Measure:

Number and percentage of participant claims in a representative sample paid for services that use approved waiver rates. (The numerator is the total number of participant claims in the review sample which paid for waiver services using approved waiver rates; the denominator is the total number of participant claims in the review sample.).

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:

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

BACBS conducts an annual review of the Medically Complex Children’s Waiver program for each of the three waiver years.

Methods for Remediation/Fixing Individual Problems

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

Recovery of Funds: • When payments are made for a service not identified on the Plan of Care, a recovery of unauthorized paid claims based upon the Federal Medical Assistance Percentage (FMAP) will be required. • When the amount of payments exceeds the amount, frequency and/or duration identified on the Plan of Care, a recovery of unauthorized paid claims based upon the Federal Medicaid Percentage (FMAP) will be required. • When payments are made for services based on a coding error, the coding error will be corrected by withdrawing the submission of the claim and submitting the correct code for payment. When BACBS discovers that unauthorized claims have been paid, BACBS works with Medicaid Operations and Medicaid Operations will reprocess the MMIS claims to reflect the recovery. When BACBS discovers that unauthorized claims have been paid, the recovery of funds will proceed as follows: 1. BACBS will complete a Recovery of Funds form that indicates the amount of the recovery and send it to Medicaid Operations 2. Medicaid Operations will reprocess the MMIS claims to reflect the recovery. 3. Overpayments are returned to the federal government within required time frames.

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:

Timelines

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

No

Yes

not selected

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

Character Count: out of 6000

Appendix I: Financial Accountability

I-2: Rates, Billing and Claims (1 of 3)

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

Character Count: out of 12000

The State Medicaid Agency is responsible for rate determination. BACBS proposes any new rates or rate changes based on rates from Utah Medicaid’s Fee schedule including rates used in existing State Plan services and Utah State 1915(c) waivers for equivalent services and providers. The proposed rates are reviewed by rate-setting staff within Medicaid’s Bureau of Coverage and Reimbursement Policy. Skilled Nursing Respite Care (Agency) - The rate used for Skilled Nursing Respite Care (Agency) is the Medicaid rate for the Private Duty Nursing (PDN) State Plan benefit. This service can be provided by either an RN or LPN. LPNs are paid a reduced rate for this service under the State Plan, as well as under the waiver. Rates for PDN were set in accordance with State Plan attachment 4.19-B, and will continue to be reviewed and updated based on the language set forth in that attachment. Skilled Nursing Respite Care (Individual) – Equivalent to 61% of the agency based rate. Because these services are offered under a family directed services model the SMA also covers the cost of employer payroll burden, including FICA, Federal and State Unemployment taxes, Workers Compensation, etc. Routine Respite (Agency) – The rate for Routine Respite in this waiver will be the same as the State Plan personal care services rate. Rates for State Plan personal care services were set in accordance with State Plan Attachment 4.19-B and will continue to be reviewed and updated based on the language set forth in that attachment. Routine Respite (Individual) – Equivalent to 61% of the agency based rate. Because these services are offered under a family directed services model the SMA also covers the cost of employer payroll burden, including FICA, Federal and State Unemployment taxes, Workers Compensation, etc. Financial Management Services – Equal to the rate paid for equivalent services in some of Utah’s other 1915(c) waivers: the Physical Disabilities and ABI Waivers. Those waivers were selected as the basis for the rate because of their comparability in expected population size, and levels of utilization of self-directed services. The state actively solicits public input on revised applications for waiver amendments or renewals from a broad network including Tribal Governments, the Medical Care Advisory Committee (MCAC), Utah Family Voices (for distribution targeted towards families and potential recipients) and the Utah Association of Home Care Pediatrics Committee which includes waiver providers and family representatives. These entities then have 30 days in which to submit comments or questions, including those involving proposed rates, for consideration prior to the submission of the final application of the Medically Complex Children’s Waiver. Providers and consumers are also invited to Medicaid public hearings to offer comments and recommendations regarding all aspects of the HCBS waiver and State plan Medicaid programs. Rates are made available to recipients and other interested parties upon request or through the State Medicaid Agency website (Utah Department of Health). All rates are subject to adjustment based on appropriations from the Utah State Legislature.
Flow of Billings. Describe the flow of billings for waiver services, specifying whether provider billings flow directly from providers to the State's claims payment system or whether billings are routed through other intermediary entities. If billings flow through other intermediary entities, specify the entities:

Character Count: out of 6000

Waiver service providers submit claims directly to the State Medicaid agency. The State Medicaid agency then pays the service provider directly. For individuals participating in the Family Directed Services model, the recipient/legal representative submits their staff time sheets to the Financial Management Service agency. The Financial Management Agency then pays the claim and submits a bill to the State Medicaid agency. The State Medicaid agency then reimburses the Financial Management agency.

Appendix I: Financial Accountability

I-2: Rates, Billing and Claims (2 of 3)

Certifying Public Expenditures (select one):

No. State or local government agencies do not certify expenditures for waiver services.

Yes. State or local government agencies directly expend funds for part or all of the cost of waiver services and certify their State government expenditures (CPE) in lieu of billing that amount to Medicaid.

Select at least one:

Certified Public Expenditures (CPE) of State Public Agencies.

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

Character Count: out of 6000

Certified Public Expenditures (CPE) of Local Government Agencies.

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

Character Count: out of 6000

Appendix I: Financial Accountability

I-2: Rates, Billing and Claims (3 of 3)

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

Character Count: out of 6000

A designated individual within Utah’s Department of Workforce Services determines recipient Medicaid eligibility. The information is entered into the eligibility system which automates Medicaid eligibility decisions, benefits amounts, recipients' notices and administrative reports. The eligibility system also interfaces with other governmental agencies such as, Social Security, Employment Security and the Internal Revenue Service. The system is a Federally-Approved Management Information System (FAMIS). In Utah, the following programs are accessed through the eligibility system: Aid to Families with Dependent Children (AFDC), Medicaid, Food Stamps and two state-administered programs - General Assistance and the Primary Care Network (PCN). The Medicaid Management Information System (MMIS) accesses the eligibility system to ensure the participant is Medicaid eligible before payment of claims is made. Post-payment reviews are conducted by BACBS as described under each assurance to ensure: (1) all of the services required by the individual are identified in the Plan of Care, (2) that the individual is receiving the services identified in the Plan of Care and (3) that Medicaid reimbursement is not claimed for waiver services which were not included in the Plan of Care.
Billing and Claims Record Maintenance Requirement. Records documenting the audit trail of adjudicated claims (including supporting documentation) are maintained by the Medicaid agency, the operating agency (if applicable), and providers of waiver services for a minimum period of 3 years as required in 45 CFR �92.42.

Appendix I: Financial Accountability

I-3: Payment (1 of 7)

Method of payments -- MMIS (select one):

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

Payments for some, but not all, waiver services are made through an approved MMIS.

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

Character Count: out of 6000

Payments for waiver services are not made through an approved MMIS.

Specify: (a) the process by which payments are made and the entity that processes payments; (b) how and through which system(s) the payments are processed; (c) how an audit trail is maintained for all state and federal funds expended outside the MMIS; and, (d) the basis for the draw of federal funds and claiming of these expenditures on the CMS-64:

Character Count: out of 6000

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

Describe how payments are made to the managed care entity or entities:

Character Count: out of 6000

not selected

Appendix I: Financial Accountability

I-3: Payment (2 of 7)

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

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

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

The Medicaid agency pays providers of some or all waiver services through the use of a limited fiscal agent.

Specify the limited fiscal agent, the waiver services for which the limited fiscal agent makes payment, the functions that the limited fiscal agent performs in paying waiver claims, and the methods by which the Medicaid agency oversees the operations of the limited fiscal agent:

Character Count: out of 6000

Providers are paid by a managed care entity or entities for services that are included in the State's contract with the entity.

Specify how providers are paid for the services (if any) not included in the State's contract with managed care entities.

Character Count: out of 6000

Appendix I: Financial Accountability

I-3: Payment (3 of 7)

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

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

Yes. The State makes supplemental or enhanced payments for waiver services.

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

Character Count: out of 6000

Appendix I: Financial Accountability

I-3: Payment (4 of 7)

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

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

Yes. State or local government providers receive payment for waiver services. Complete Item I-3-e.

Specify the types of State or local government providers that receive payment for waiver services and the services that the State or local government providers furnish:

Character Count: out of 4000

not selected

Appendix I: Financial Accountability

I-3: Payment (5 of 7)

Amount of Payment to State or Local Government Providers.

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

Answers provided in Appendix I-3-d indicate that you do not need to complete this section.

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

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

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

Describe the recoupment process:

Character Count: out of 6000

Appendix I: Financial Accountability

I-3: Payment (6 of 7)

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

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

Providers do not receive and retain 100 percent of the amount claimed to CMS for waiver services.

Provide a full description of the billing, claims, or payment processes that result in less than 100% reimbursement of providers. Include: (a) the methodology for reduced or returned payments; (b) a complete listing of types of providers, the amount or percentage of payments that are reduced or returned; and, (c) the disposition and use of the funds retained or returned to the State (i.e., general fund, medical services account, etc.):

Character Count: out of 12000

Providers are paid by a managed care entity (or entities) that is paid a monthly capitated payment.

Specify whether the monthly capitated payment to managed care entities is reduced or returned in part to the State.

Character Count: out of 12000

not selected

Appendix I: Financial Accountability

I-3: Payment (7 of 7)

Additional Payment Arrangements

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

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

Yes. Providers may voluntarily reassign their right to direct payments to a governmental agency as provided in 42 CFR §447.10(e).

Specify the governmental agency (or agencies) to which reassignment may be made.

Character Count: out of 4000

Organized Health Care Delivery System. Select one:

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

Yes. The waiver provides for the use of Organized Health Care Delivery System arrangements under the provisions of 42 CFR §447.10.

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

Character Count: out of 18000

Contracts with MCOs, PIHPs or PAHPs. Select one:

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

The State contracts with a Managed Care Organization(s) (MCOs) and/or prepaid inpatient health plan(s) (PIHP) or prepaid ambulatory health plan(s) (PAHP) under the provisions of §1915(a)(1) of the Act for the delivery of waiver and other services. Participants may voluntarily elect to receive waiver and other services through such MCOs or prepaid health plans. Contracts with these health plans are on file at the State Medicaid agency.

Describe: (a) the MCOs and/or health plans that furnish services under the provisions of §1915(a)(1); (b) the geographic areas served by these plans; (c) the waiver and other services furnished by these plans; and, (d) how payments are made to the health plans.

Character Count: out of 18000

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

not selected

Appendix I: Financial Accountability

I-4: Non-Federal Matching Funds (1 of 3)

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

Appropriation of State Tax Revenues to the State Medicaid agency

Appropriation of State Tax Revenues to a State Agency other than the Medicaid Agency.

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

Character Count: out of 6000

Other State Level Source(s) of Funds.

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

Character Count: out of 6000

Appendix I: Financial Accountability

I-4: Non-Federal Matching Funds (2 of 3)

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

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

Applicable

Check each that applies:

Not Applicable. There are no non-State level sources of funds for the non-federal share.

Appropriation of Local Government Revenues.

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

Character Count: out of 6000

Other Local Government Level Source(s) of Funds.

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

Character Count: out of 6000

not selected

Appendix I: Financial Accountability

I-4: Non-Federal Matching Funds (3 of 3)

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

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

The following source(s) are used

Check each that applies:

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

Health care-related taxes or fees

Provider-related donations

Federal funds

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

Character Count: out of 6000

not selected

Appendix I: Financial Accountability

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

Services Furnished in Residential Settings. Select one:

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

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

not selected
Method for Excluding the Cost of Room and Board Furnished in Residential Settings. The following describes the methodology that the State uses to exclude Medicaid payment for room and board in residential settings:
Do not complete this item.

Character Count: out of 12000

Appendix I: Financial Accountability

I-6: Payment for Rent and Food Expenses of an Unrelated Live-In Caregiver

Reimbursement for the Rent and Food Expenses of an Unrelated Live-In Personal Caregiver. Select one:

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

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

The following is an explanation of: (a) the method used to apportion the additional costs of rent and food attributable to the unrelated live-in personal caregiver that are incurred by the individual served on the waiver and (b) the method used to reimburse these costs:

Character Count: out of 6000

Appendix I: Financial Accountability

I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (1 of 5)

Co-Payment Requirements. Specify whether the State imposes a co-payment or similar charge upon waiver participants for waiver services. These charges are calculated per service and have the effect of reducing the total computable claim for federal financial participation. Select one:

No. The State does not impose a co-payment or similar charge upon participants for waiver services.

Yes. The State imposes a co-payment or similar charge upon participants for one or more waiver services.
1. Co-Pay Arrangement.
  
  Specify the types of co-pay arrangements that are imposed on waiver participants (check each that applies):
  
  Charges Associated with the Provision of Waiver Services (if any are checked, complete Items I-7-a-ii through I-7-a-iv):
  
  Nominal deductible
  
  Coinsurance
  
  Co-Payment
  
  Other charge
  
  Specify:
  
  Character Count: out of 6000
not selected

Appendix I: Financial Accountability

I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (2 of 5)

Co-Payment Requirements.
1. Participants Subject to Co-pay Charges for Waiver Services.
  
  Answers provided in Appendix I-7-a indicate that you do not need to complete this section.

Appendix I: Financial Accountability

I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (3 of 5)

Co-Payment Requirements.
1. Amount of Co-Pay Charges for Waiver Services.
  
  Answers provided in Appendix I-7-a indicate that you do not need to complete this section.

Appendix I: Financial Accountability

I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (4 of 5)

Co-Payment Requirements.
1. Cumulative Maximum Charges.
  
  Answers provided in Appendix I-7-a indicate that you do not need to complete this section.

Appendix I: Financial Accountability

I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (5 of 5)

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

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

Yes. The State imposes a premium, enrollment fee or similar cost-sharing arrangement.

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

Character Count: out of 12000

Appendix J: Cost Neutrality Demonstration

J-1: Composite Overview and Demonstration of Cost-Neutrality Formula

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

Level(s) of Care: Nursing Facility

Col. 1	Col. 2	Col. 3	Col. 4	Col. 5	Col. 6	Col. 7	Col. 8
Year	Factor D	Factor D'	Total: D+D'	Factor G	Factor G'	Total: G+G'	Difference (Col 7 less Column4)
1	4283.95		17498.20			52185.18	34686.98
2	5711.94		23330.94			69197.55	45866.61
3	5711.94		23330.94			70581.49	47250.55

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (1 of 7)

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

Table: J-2-a: Unduplicated Participants
Waiver Year	Total Unduplicated Number of Participants (from Item B-3-a)	Distribution of Unduplicated Participants by Level of Care (if applicable)
		Level of Care:
		Nursing Facility
		Year 1	175
Year 2	175
Year 3	175

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (2 of 7)

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

Character Count: out of 6000

Average Length of Stay (LOS) = 270 days for waiver year 1 and 360 days for waiver years 2 and 3. Waiver year 1 LOS assumes a 90 day period of time for participants to be determined to meet the eligibility requirements and begin services. Waiver years two and three assume virtually no attrition as the broad age range of potential participants will likely not result any attrition due to age, we also assume few, if any, voluntary disenrollments

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (3 of 7)

Derivation of Estimates for Each Factor. Provide a narrative description for the derivation of the estimates of the following factors.
1. Factor D Derivation. The estimates of Factor D for each waiver year are located in Item J-2-d. The basis for these estimates is as follows:
  
  Character Count: out of 12000
  
  Factor D was derived based on the following assumptions: 1) Average per user utilization of skilled nursing respite: 2 hours per week 2) Average per user utilization of routine respite: 1 hour per week 3) 10% of Skilled Nursing Respite users will employ a family directed services model 4) All participants will employ a family directed services model for routine respite requiring all participants to utilize 1 unit of Financial Management Services per month The SMA will monitor these assumptions following implementation of the waiver and adjust estimates as necessary.
2. Factor D' Derivation. The estimates of Factor D' for each waiver year are included in Item J-1. The basis of these estimates is as follows:
  
  Character Count: out of 12000
  
  Factor D’ was derived based on Idaho Medicaid’s estimates for average cost per year for participants in their Katie Beckett program. The estimate of costs used for factor D’ in this initial waiver submission does not explicitly exclude costs associated with prescription drugs. However because of the unique nature of the population anticipated to be served no estimate of the cost for prescription drugs was readily available. The State commits to exclude any costs associated with prescription drugs from costs reported in the 372 reports submitted for this waiver. The State’s methodology for excluding those costs from the 372 reports is listed below. The State’s MMIS system assigns a single category of service to each claim during claims processing. All claims for prescription drugs are assigned to category of service 30. When generating estimates of D’ or G’ in the 372 report, this category of service is explicitly removed from data queries used to compile the report.
3. Factor G Derivation. The estimates of Factor G for each waiver year are included in Item J-1. The basis of these estimates is as follows:
  
  Character Count: out of 12000
  
  Factor G was derived based on the following assumptions: 1) Used actual average nursing home cost per day for fiscal years 2012-2014 and multiplied by the estimated waiver LOS to get fiscal year 2015 base estimate and the increased by 2% to get Waiver year one 2) Each subsequent year was increased 2%. This amount was based on trending data from FY2012-FY2014. The amount appears to be consistent with the Consumer Price Index for Medical services and also aligns with growth in the legislation of Utah’s Accountable Care Organizations.
4. Factor G' Derivation. The estimates of Factor G' for each waiver year are included in Item J-1. The basis of these estimates is as follows:
  
  Character Count: out of 12000
  
  Factor G’ was derived based on the following assumptions: 1) Used actual average nursing home cost per day for fiscal years 2012-2014 and multiplied by the estimated waiver LOS to get fiscal year 2015 base estimate and the increased by 2% to get Waiver year one 2) Each subsequent year was increased 2%. This amount was based on trending data from FY2012-FY2014. The amount appears to be consistent with the Consumer Price Index for Medical services and also aligns with growth in the legislation of Utah’s Accountable Care Organizations. 3) The state utilizes the MMIS Categories of Service and Provider Type functionality to account for and exclude the costs of prescribed drugs from G'

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (4 of 7)

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

Waiver Services
Skilled Nursing Respite and Routine Respite
Financial Management Services

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (5 of 7)

Estimate of Factor D.

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

Waiver Year: Year 1

Waiver Service/ Component

Unit

# Users

Avg. Units Per User

Avg. Cost/ Unit

Component Cost

Total Cost

Skilled Nursing Respite and Routine Respite Total:

668311.80

Skilled Respite - Agency

553612.80

Skilled Respite - Self-Directed

31683.60

Routine Respite - Agency

3720.60

Routine Respite - Self-Directed

79294.80

Financial Management Services Total:

81380.25

Financial Management Services

81380.25

GRAND TOTAL:	749692.05
Total Estimated Unduplicated Participants:	175
Factor D (Divide total by number of participants):	4283.95
Average Length of Stay on the Waiver:

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (6 of 7)

Estimate of Factor D.

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

Waiver Year: Year 2

Waiver Service/ Component

Unit

# Users

Avg. Units Per User

Avg. Cost/ Unit

Component Cost

Total Cost

Skilled Nursing Respite and Routine Respite Total:

891082.40

Skilled Respite - Agency

738150.40

Skilled Respite - Self-Directed

42244.80

Routine Respite - Agency

4960.80

Routine Respite - Self-Directed

105726.40

Financial Management Services Total:

108507.00

Financial Management Services

108507.00

GRAND TOTAL:	999589.40
Total Estimated Unduplicated Participants:	175
Factor D (Divide total by number of participants):	5711.94
Average Length of Stay on the Waiver:

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (7 of 7)

Estimate of Factor D.

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

Waiver Year: Year 3

Waiver Service/ Component

Unit

# Users

Avg. Units Per User

Avg. Cost/ Unit

Component Cost

Total Cost

Skilled Nursing Respite and Routine Respite Total:

891082.40

Skilled Respite - Agency

738150.40

Skilled Respite - Self-Directed

42244.80

Routine Respite - Agency

4960.80

Routine Respite - Self-Directed

105726.40

Financial Management Services Total:

108507.00

Financial Management Services

108507.00

GRAND TOTAL:	999589.40
Total Estimated Unduplicated Participants:	175
Factor D (Divide total by number of participants):	5711.94
Average Length of Stay on the Waiver: