PURPOSE OF THE HCBS WAIVER PROGRAM

1. Major Changes

1. Request Information (1 of 3)

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

   New Choices Waiver
3. Type of Request: renewal
   Requested Approval Period:(For new waivers requesting five year approval periods, the waiver must serve individuals who are dually eligible for Medicaid and Medicare.)

   3 years

   5 years

   Original Base Waiver Number: UT.0439
   Waiver Number:UT.0439.R02.00
   Draft ID:UT.008.02.00
4. Type of Waiver (select only one):
   Model Waiver Regular Waiver
5. Proposed Effective Date: (mm/dd/yy)
   Approved Effective Date: 07/01/15

1. Request Information (2 of 3)

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

    Hospital as defined in 42 CFR §440.10

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

   Character Count: out of 6000

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

    not selected
   Nursing Facility
   Select applicable level of care

    Nursing Facility as defined in 42 CFR ��440.40 and 42 CFR ��440.155

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

   Character Count: out of 6000

   Medicaid participants classified as meeting the Intensive Skilled level of care are not eligible for this waiver.

    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)

7. Concurrent Operation with Other Programs. This waiver operates concurrently with another program (or programs) approved under the following authorities
   Select one:
    Not applicable
    Applicable
   Check the applicable authority or authorities:

   Services furnished under the provisions of §1915(a)(1)(a) of the Act and described in Appendix I

   Waiver(s) authorized under §1915(b) of the Act.

   Specify the §1915(b) waiver program and indicate whether a §1915(b) waiver application has been submitted or previously approved:

   Character Count: out of 6000

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

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

   §1915(b)(2) (central broker)

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

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

   A program operated under §1932(a) of the Act.

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

   Character Count: out of 6000

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

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

   A program authorized under §1115 of the Act.

   Specify the program:

   Character Count: out of 6000

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

2. Brief Waiver Description

3. Components of the Waiver Request

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

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

2. Participant Access and Eligibility. Appendix B specifies the target group(s) of individuals who are served in this waiver, the number of participants that the State expects to serve during each year that the waiver is in effect, applicable Medicaid eligibility and post-eligibility (if applicable) requirements, and procedures for the evaluation and reevaluation of level of care.

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

4. Participant-Centered Service Planning and Delivery. Appendix D specifies the procedures and methods that the State uses to develop, implement and monitor the participant-centered service plan (of care).

5. Participant-Direction of Services. When the State provides for participant direction of services, Appendix E specifies the participant direction opportunities that are offered in the waiver and the supports that are available to participants who direct their services. (Select one):
    Yes. This waiver provides participant direction opportunities. Appendix E is required.

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

    not selected

6. Participant Rights. Appendix F specifies how the State informs participants of their Medicaid Fair Hearing rights and other procedures to address participant grievances and complaints.

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

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

9. Financial Accountability. Appendix I describes the methods by which the State makes payments for waiver services, ensures the integrity of these payments, and complies with applicable federal requirements concerning payments and federal financial participation.

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

4. Waiver(s) Requested

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

    No

    Yes

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

   No

   Yes

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

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

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

   Character Count: out of 6000

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

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

   Character Count: out of 6000

5. Assurances

1. Health & Welfare: The State assures that necessary safeguards have been taken to protect the health and welfare of persons receiving services under this waiver. These safeguards include:

   1. As specified in Appendix C, adequate standards for all types of providers that provide services under this waiver;

   2. Assurance that the standards of any State licensure or certification requirements specified in Appendix C are met for services or for individuals furnishing services that are provided under the waiver. The State assures that these requirements are met on the date that the services are furnished; and,

   3. Assurance that all facilities subject to §1616(e) of the Act where home and community-based waiver services are provided comply with the applicable State standards for board and care facilities as specified in Appendix C.

2. Financial Accountability. The State assures financial accountability for funds expended for home and community-based services and maintains and makes available to the Department of Health and Human Services (including the Office of the Inspector General), the Comptroller General, or other designees, appropriate financial records documenting the cost of services provided under the waiver. Methods of financial accountability are specified in Appendix I.

3. Evaluation of Need: The State assures that it provides for an initial evaluation (and periodic reevaluations, at least annually) of the need for a level of care specified for this waiver, when there is a reasonable indication that an individual might need such services in the near future (one month or less) but for the receipt of home and community-based services under this waiver. The procedures for evaluation and reevaluation of level of care are specified in Appendix B.

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

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

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

5. Average Per Capita Expenditures: The State assures that, for any year that the waiver is in effect, the average per capita expenditures under the waiver will not exceed 100 percent of the average per capita expenditures that would have been made under the Medicaid State plan for the level(s) of care specified for this waiver had the waiver not been granted. Cost-neutrality is demonstrated in Appendix J.

6. Actual Total Expenditures: The State assures that the actual total expenditures for home and community-based waiver and other Medicaid services and its claim for FFP in expenditures for the services provided to individuals under the waiver will not, in any year of the waiver period, exceed 100 percent of the amount that would be incurred in the absence of the waiver by the State's Medicaid program for these individuals in the institutional setting(s) specified for this waiver.

7. Institutionalization Absent Waiver: The State assures that, absent the waiver, individuals served in the waiver would receive the appropriate type of Medicaid-funded institutional care for the level of care specified for this waiver.

8. Reporting: The State assures that annually it will provide CMS with information concerning the impact of the waiver on the type, amount and cost of services provided under the Medicaid State plan and on the health and welfare of waiver participants. This information will be consistent with a data collection plan designed by CMS.

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

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

6. Additional Requirements

1. Service Plan. In accordance with 42 CFR §441.301(b)(1)(i), a participant-centered service plan (of care) is developed for each participant employing the procedures specified in Appendix D. All waiver services are furnished pursuant to the service plan. The service plan describes: (a) the waiver services that are furnished to the participant, their projected frequency and the type of provider that furnishes each service and (b) the other services (regardless of funding source, including State plan services) and informal supports that complement waiver services in meeting the needs of the participant. The service plan is subject to the approval of the Medicaid agency. Federal financial participation (FFP) is not claimed for waiver services furnished prior to the development of the service plan or for services that are not included in the service plan.

2. Inpatients. In accordance with 42 CFR §441.301(b)(1)(ii), waiver services are not furnished to individuals who are in-patients of a hospital, nursing facility or ICF/IID.

3. Room and Board. In accordance with 42 CFR §441.310(a)(2), FFP is not claimed for the cost of room and board except when: (a) provided as part of respite services in a facility approved by the State that is not a private residence or (b) claimed as a portion of the rent and food that may be reasonably attributed to an unrelated caregiver who resides in the same household as the participant, as provided in Appendix I.

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

5. Free Choice of Provider. In accordance with 42 CFR §431.151, a participant may select any willing and qualified provider to furnish waiver services included in the service plan unless the State has received approval to limit the number of providers under the provisions of §1915(b) or another provision of the Act.

6. FFP Limitation. In accordance with 42 CFR §433 Subpart D, FFP is not claimed for services when another third-party (e.g., another third party health insurer or other federal or state program) is legally liable and responsible for the provision and payment of the service. FFP also may not be claimed for services that are available without charge, or as free care to the community. Services will not be considered to be without charge, or free care, when (1) the provider establishes a fee schedule for each service available and (2) collects insurance information from all those served (Medicaid, and non-Medicaid), and bills other legally liable third party insurers. Alternatively, if a provider certifies that a particular legally liable third party insurer does not pay for the service(s), the provider may not generate further bills for that insurer for that annual period.

7. Fair Hearing: The State provides the opportunity to request a Fair Hearing under 42 CFR §431 Subpart E, to individuals: (a) who are not given the choice of home and community-based waiver services as an alternative to institutional level of care specified for this waiver; (b) who are denied the service(s) of their choice or the provider(s) of their choice; or (c) whose services are denied, suspended, reduced or terminated. Appendix F specifies the State's procedures to provide individuals the opportunity to request a Fair Hearing, including providing notice of action as required in 42 CFR §431.210.

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

9. Public Input. Describe how the State secures public input into the development of the waiver:
   Character Count: out of 6000
   The State Medicaid Agency completed the initial draft renewal application in September, 2014. The State Medicaid Agency met statewide with providers and case management agencies from September to October 2014. Amendments to the draft were completed October 2014. The revised draft was posted for review by a broad network of consumers, advocates, providers and Tribal Governments and the Medical Care Advisory Committee (MCAC) in February 2015. The entities had 30 days in which to submit comments or questions about the Waiver Application. The State seeks and obtains public input via the method listed above each time the New Choices Waiver is renewed. Prior to posting the renewal application for public comment, a stakeholder meeting was held on January 28, 2015 to specifically hear feedback related to the proposal to reserve capacity for long term residents of nursing facilities who wish to return to a home or community-based setting. The State then sought public input by posting a copy of the proposed amendment online for a period of 30 days. The state also conferred with the Utah Indian Health Advisory Board (UIHAB) on January 9, 2015 and again on March 13, 2015.

10. Notice to Tribal Governments. The State assures that it has notified in writing all federally-recognized Tribal Governments that maintain a primary office and/or majority population within the State of the State's intent to submit a Medicaid waiver request or renewal request to CMS at least 60 days before the anticipated submission date is provided by Presidential Executive Order 13175 of November 6, 2000. Evidence of the applicable notice is available through the Medicaid Agency.

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

7. Contact Person(s)

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

   First Name:

   Title:

   Agency:

   Address:

   Address 2:

   City:

   State:

   Utah

   Zip:

   Phone:

   Ext: TTY

   Fax:

   E-mail:

2. If applicable, the State operating agency representative with whom CMS should communicate regarding the waiver is:
   Last Name:

   First Name:

   Title:

   Agency:

   Address:

   Address 2:

   City:

   State:

   Utah

   Zip:

   Phone:

   Ext: TTY

   Fax:

   E-mail:

8. Authorizing Signature

Attachments

Specify the transition plan for the waiver:

Additional Needed Information (Optional)

Appendix A: Waiver Administration and Operation

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

    The waiver is operated by the State Medicaid agency.

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

    The Medical Assistance Unit.

   Specify the unit name:Utah Division of Medicaid and Health Financing, Bureau of Authorization and Community Based Services (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

2. Oversight of Performance.

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

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

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

Appendix A: Waiver Administration and Operation

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

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

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

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

   Character Count: out of 6000

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

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

   Character Count: out of 6000

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

Appendix A: Waiver Administration and Operation

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

Appendix A: Waiver Administration and Operation

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

Appendix A: Waiver Administration and Operation

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

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

Appendix A: Waiver Administration and Operation

Quality Improvement: Administrative Authority of the Single State Medicaid Agency

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

   1. Performance Measures

      For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Performance measures for administrative authority should not duplicate measures found in other appendices of the waiver application. As necessary and applicable, performance measures should focus on:

      • Uniformity of development/execution of provider agreements throughout all geographic areas covered by the waiver
      • Equitable distribution of waiver openings in all geographic areas covered by the waiver
      • Compliance with HCB settings requirements and other new regulatory components (for waiver actions submitted on or after March 17, 2014)

      Where possible, include numerator/denominator.

      For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
   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
2. Methods for Remediation/Fixing Individual Problems
   1. Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.
      Character Count: out of 6000
      Individual issues identified 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 New Choices Waiver Unit, case management and/or direct care provider agencies requiring an immediate review and remediation of the issue, reporting the issue to Adult Protective Services 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 to the waiver participant and documentation is maintained by the SMA.
   2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)

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

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

    No

    Yes

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

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

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

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

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

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

   Character Count: out of 12000
   Participation in the New Choices Waiver is limited to individuals who at the time of application: 1. are 18 years of age or older; 2. (a) are receiving nursing facility care and have been continuously receiving nursing facility care for a minimum of 90 days prior to admission; or (b) are receiving care in a small health care facility (Type N) and have been continuously receiving Type N facility care for a minimum of 365 days prior to application; or (c) are receiving licensed assisted living facility care and have been continuously receiving licensed assisted living facility care for a minimum of 365 days prior to application; or (d) are receiving Medicare or Medicaid reimbursed care in another type of Utah licensed medical institution that is not an institution for mental disease (IMD), on an extended stay of at least 30 days, and will discharge to a nursing facility for an extended stay of at least 60 days absent enrollment into the waiver program; or (e) are receiving Medicaid reimbursed services through another of Utah’s 1915(c) waivers and have been identified in need of immediate (or near immediate) nursing facility admission absent enrollment into this waiver program; or (f) have previously been enrolled in the New Choices Waiver but were disenrolled from the waiver due to a long term nursing facility admission or due to receipt of a lump sum payment or other financial settlement that resulted in loss of Medicaid financial eligibility. Re-enrollment is permitted when there has been no interruption in services equivalent to nursing facility care including equivalent home and community-based waiver services paid privately or by another funding source. (A new nursing facility level of care assessment must be performed prior to readmission.) 3. For individuals leaving acute care hospitals, specialty hospitals (non IMD), and Medicare skilled nursing facilities, participation is limited to those receiving a medical, non-psychiatric level of care. 4. Individuals who meet the intensive skilled level of care as provided in R414-502 are not eligible for participation in the New Choices Waiver. 5. Individuals who meet the level of care criteria for admission to an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-ID) as provided in R414-502 are not eligible for participation in the New Choices Waiver.

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

   Not applicable. There is no maximum age limit

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

   Specify:

   Character Count: out of 12000

   Disabled transition to Aged

Appendix B: Participant Access and Eligibility

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

1. Individual Cost Limit. The following individual cost limit applies when determining whether to deny home and community-based services or entrance to the waiver to an otherwise eligible individual (select one). Please note that a State may have only ONE individual cost limit for the purposes of determining eligibility for the waiver:
    No Cost Limit. The State does not apply an individual cost limit. Do not complete Item B-2-b or item B-2-c.
    Cost Limit in Excess of Institutional Costs. The State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed the cost of a level of care specified for the waiver up to an amount specified by the State. Complete Items B-2-b and B-2-c.

   The limit specified by the State is (select one)

    A level higher than 100% of the institutional average.

   Specify the percentage:

    Other

   Specify:

   Character Count: out of 6000

    not selected
    Institutional Cost Limit. Pursuant to 42 CFR 441.301(a)(3), the State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed 100% of the cost of the level of care specified for the waiver. Complete Items B-2-b and B-2-c.
    Cost Limit Lower Than Institutional Costs. The State refuses entrance to the waiver to any otherwise qualified individual when the State reasonably expects that the cost of home and community-based services furnished to that individual would exceed the following amount specified by the State that is less than the cost of a level of care specified for the waiver.

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

   Character Count: out of 6000

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

    The following dollar amount:

   Specify dollar amount:

   The dollar amount (select one)

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

   Specify the formula:

   Character Count: out of 6000

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

    not selected

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

   Specify percent:

    Other:

   Specify:

   Character Count: out of 6000

    not selected
    not selected

Appendix B: Participant Access and Eligibility

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

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

2. Method of Implementation of the Individual Cost Limit. When an individual cost limit is specified in Item B-2-a, specify the procedures that are followed to determine in advance of waiver entrance that the individual's health and welfare can be assured within the cost limit:
   Character Count: out of 12000
3. Participant Safeguards. When the State specifies an individual cost limit in Item B-2-a and there is a change in the participant's condition or circumstances post-entrance to the waiver that requires the provision of services in an amount that exceeds the cost limit in order to assure the participant's health and welfare, the State has established the following safeguards to avoid an adverse impact on the participant (check each that applies):
   The participant is referred to another waiver that can accommodate the individual's needs.
   Additional services in excess of the individual cost limit may be authorized.

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

   Character Count: out of 12000
   Other safeguard(s)

   Specify:

   Character Count: out of 12000

Appendix B: Participant Access and Eligibility

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

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

   Table: B-3-a

   Waiver Year	Unduplicated Number of Participants
   Year 1
   Year 2
   Year 3
   Year 4
   Year 5

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

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

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

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

   Table: B-3-b

   Waiver Year	Maximum Number of Participants Served At Any Point During the Year
   Year 1
   Year 2
   Year 3
   Year 4
   Year 5

Appendix B: Participant Access and Eligibility

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

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

   Not applicable. The state does not reserve capacity.

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

   Purpose(s) the State reserves capacity for:

   Purposes
   Focus on deinstitutionalization

Appendix B: Participant Access and Eligibility

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

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

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

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

5. Allocation of Waiver Capacity.

   Select one:

   Waiver capacity is allocated/managed on a statewide basis.

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

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

   Character Count: out of 12000
6. Selection of Entrants to the Waiver. Specify the policies that apply to the selection of individuals for entrance to the waiver:
   Character Count: out of 12000
   At the beginning of each waiver year, the SMA NCW Unit will calculate the total number of available waiver slots. 620 slots will be reserved for residents of hospitals, nursing facilities and other Utah licensed medical institutions (non-IMD). For applicants residing in hospitals, nursing facilities or other Utah licensed medical institutions (non-IMD), no selection policies apply beyond the waiver targeting criteria described in Appendix B-1. The remaining non-reserved available waiver slots (the slots that are not reserved for hospital and nursing facility residents) can be accessed by any applicant outside the reserved capacity slots who meets the waiver eligibility criteria. For applicants wishing to apply for the non-reserved slots, the following selection of entrants will be employed: On a tri-annual basis, the SMA NCW Unit will open an application period for anyone meeting the eligibility criteria and who wishes to apply for the non-reserved slots. The SMA NCW Unit will enroll up to 33.33% of the remaining non-reserved slots. At the beginning of each tri-annual period, the SMA NCW Unit will provide an open application period of 14 days during which time applications will be accepted from all interested applicants. At the end of the open application period the SMA NCW Unit will conduct an initial eligibility screening of each application received to determine whether the following minimum screening criteria is met: 1. The applicant resided in a qualifying facility type for at least the required number of days (depending upon the facility type in which they reside as specified in Appendix B-1-b) by the end of the open application period. 2. The applicant reached 18 years of age or older by the end of the open application period. 3. Medical records provided with the application appear to indicate the applicant has care needs that require nursing facility level of care or equivalent care provided by a home and community-based services waiver program. Applications that do not meet the initial screening criteria listed above will be returned and hearing rights will be provided. If the number of applications received during an open application period is equal to or less than the number of slots available during that application period, all applicants meeting waiver criteria will be enrolled in the waiver. During either of the first two (2) tri-annual open application periods of a waiver year, if fewer qualifying applications are received than the number of available slots, the unfilled slots may carry over to the next open application period. During the third tri-annual open application period of a waiver year, the SMA NCW Unit will calculate the number of remaining non-reserved waiver slots and open one final open application period. If fewer qualifying applications are received than the number of available slots, the unfilled slots will not carry over. If more applications are received than there is space available for a particular application period, the SMA NCW Unit will rank applicants based on length of stay. (Applicants who have been residing in a qualifying facility type the longest will be given preference.) When this ranking has been completed, the SMA NCW Unit will return all applications above the number of available slots for that application period and hearing rights will be provided. In the event there is a length of stay tie at the cut-off point, all applicants in the tie who meet waiver criteria will be enrolled in the waiver. The number of enrollees above 33.33% for that open application period will be deducted from the number of enrollees permitted in the next open application period.

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

1. 1. State Classification. The State is a (select one):
       §1634 State
       SSI Criteria State
       209(b) State
       not selected
   2. Miller Trust State.
      Indicate whether the State is a Miller Trust State (select one):
       No
       Yes
       Unknown
2. Medicaid Eligibility Groups Served in the Waiver. Individuals who receive services under this waiver are eligible under the following eligibility groups contained in the State plan. The State applies all applicable federal financial participation limits under the plan. Check all that apply:
   Eligibility Groups Served in the Waiver (excluding the special home and community-based waiver group under 42 CFR §435.217)
   Low income families with children as provided in §1931 of the Act
   SSI recipients
   Aged, blind or disabled in 209(b) states who are eligible under 42 CFR §435.121
   Optional State supplement recipients
   Optional categorically needy aged and/or disabled individuals who have income at:

   Select one:

    100% of the Federal poverty level (FPL)

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

   Specify percentage:

    not selected
   Working individuals with disabilities who buy into Medicaid (BBA working disabled group as provided in §1902(a)(10)(A)(ii)(XIII)) of the Act)
   Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1902(a)(10)(A)(ii)(XV) of the Act)
   Working individuals with disabilities who buy into Medicaid (TWWIIA Medical Improvement Coverage Group as provided in §1902(a)(10)(A)(ii)(XVI) of the Act)
   Disabled individuals age 18 or younger who would require an institutional level of care (TEFRA 134 eligibility group as provided in §1902(e)(3) of the Act)
   Medically needy
   Medically needy in 209(b) States (42 CFR §435.330)
   Medically needy in 1634 States and SSI Criteria States (42 CFR §435.320, §435.322 and §435.324)
   Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver)

   Specify:

   Character Count: out of 6000

   42 CFR 435.135, 1634(c)(DAC)/1634(d) 1619b
   Special home and community-based waiver group under 42 CFR §435.217) Note: When the special home and community-based waiver group under 42 CFR §435.217 is included, Appendix B-5 must be completed
    No. The State does not furnish waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217. Appendix B-5 is not submitted.

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

    not selected

   Select one and complete Appendix B-5.

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

    Only the following groups of individuals in the special home and community-based waiver group under 42 CFR §435.217

    not selected

   Check each that applies:

   A special income level equal to:

   Select one:

    300% of the SSI Federal Benefit Rate (FBR)

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

   Specify percentage:

    A dollar amount which is lower than 300%.

   Specify dollar amount:

    not selected

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

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

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

   Aged and disabled individuals who have income at:

   Select one:

    100% of FPL

    % of FPL, which is lower than 100%.

   Specify percentage amount:

    not selected

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

   Specify:

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

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

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

1. Use of Spousal Impoverishment Rules. Indicate whether spousal impoverishment rules are used to determine eligibility for the special home and community-based waiver group under 42 CFR §435.217:

   Note: For the five-year period beginning January 1, 2014, the following instructions are mandatory. The following box should be checked for all waivers that furnish waiver services to the 42 CFR §435.217 group effective at any point during this time period.
   Spousal impoverishment rules under §1924 of the Act are used to determine the eligibility of individuals with a community spouse for the special home and community-based waiver group. In the case of a participant with a community spouse, the State uses spousal post-eligibility rules under §1924 of the Act.
   Complete Items B-5-e (if the selection for B-4-a-i is SSI State or §1634) or B-5-f (if the selection for B-4-a-i is 209b State) and Item B-5-g unless the state indicates that it also uses spousal post-eligibility rules for the time periods before January 1, 2014 or after December 31, 2018.
   Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018 (select one).
    Spousal impoverishment rules under §1924 of the Act are used to determine the eligibility of individuals with a community spouse for the special home and community-based waiver group.

   In the case of a participant with a community spouse, the State elects to (select one):

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

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

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

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

    not selected

    Spousal impoverishment rules under §1924 of the Act are not used to determine eligibility of individuals with a community spouse for the special home and community-based waiver group. The State uses regular post-eligibility rules for individuals with a community spouse.

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

    not selected

Appendix B: Participant Access and Eligibility

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

2. Regular Post-Eligibility Treatment of Income: SSI State.

   The State uses the post-eligibility rules at 42 CFR 435.726 for individuals who do not have a spouse or have a spouse who is not a community spouse as specified in §1924 of the Act. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the following allowances and expenses from the waiver participant's income:

   1. Allowance for the needs of the waiver participant (select one):

       The following standard included under the State plan

      Select one:

       SSI standard

       Optional State supplement standard

       Medically needy income standard

       The special income level for institutionalized persons

      (select one):

       300% of the SSI Federal Benefit Rate (FBR)

       A percentage of the FBR, which is less than 300%

      Specify the percentage:

       A dollar amount which is less than 300%.

      Specify dollar amount:

       not selected

       A percentage of the Federal poverty level

      Specify percentage:

       Other standard included under the State Plan

      Specify:

      Character Count: out of 36000

       not selected
       The following dollar amount

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

      Specify:

      Character Count: out of 6000

      Up to $125 of any earned income and a general disregard of 100% of the FPL for one person; plus shelter cost deduction for mortgage & related costs (property taxes, insurance, etc.) or rent, not to exceed $300; plus the standard utility allowance Utah uses under Section 5(e) of the Food Stamp Act of 1977. Total shelter costs cannot exceed $300 plus the standard utility allowance. If other family members live with the waiver client, an additional amount in recognition of higher expenses that a waiver client may have to meet the extra costs of supporting the other family members will be considered, The additional amount is the difference between the allowance for a family member defined in Section 1924(d)(1)(C) of the Social Security Act and the allowance for a family member defined in 42 CFR435.726(c)(3).
       Other

      Specify:

      Character Count: out of 6000
       not selected

   2. Allowance for the spouse only (select one):

       Not Applicable
       The state provides an allowance for a spouse who does not meet the definition of a community spouse in §1924 of the Act. Describe the circumstances under which this allowance is provided:

      Specify:

      Character Count: out of 6000

      Specify the amount of the allowance (select one):

       SSI standard

       Optional State supplement standard

       Medically needy income standard

       The following dollar amount:

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

       The amount is determined using the following formula:

      Specify:

      Character Count: out of 6000

       not selected
       not selected

   3. Allowance for the family (select one):

       Not Applicable (see instructions)
       AFDC need standard
       Medically needy income standard
       The following dollar amount:

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

      Specify:

      Character Count: out of 6000
       Other

      Specify:

      Character Count: out of 6000
       not selected

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

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

      Select one:

       Not Applicable (see instructions)Note: If the State protects the maximum amount for the waiver participant, not applicable must be selected.
       The State does not establish reasonable limits.
       The State establishes the following reasonable limits

      Specify:

      Character Count: out of 6000

      The State establishes the following reasonable limits: The limits specified in Utah’s Title XIX State Plan for post-eligibility income deductions under 42 CFR 435.725, 435.726, 435.832 and Sec. 1924 of the Social Security Act. The limits are defined on supplement 3 to attachment 2.6A.
       not selected

Appendix B: Participant Access and Eligibility

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

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

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

Appendix B: Participant Access and Eligibility

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

4. Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules

   The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care if it determines the individual's eligibility under §1924 of the Act. There is deducted from the participant's monthly income a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the State Medicaid Plan. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).

   1. Allowance for the personal needs of the waiver participant

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

      Specify percentage:
       The following dollar amount:

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

      Specify formula:

      Character Count: out of 4000

      Up to $125 of any earned income and a general disregard of 100% of the FPL for one person; plus shelter cost deduction for mortgage & related costs (property taxes, insurance, etc.) or rent, not to exceed $300; plus the standard utility allowance Utah uses under Section 5(e) of the Food Stamp Act of 1977. Total shelter costs cannot exceed $300 plus the standard utility allowance.
       Other

      Specify:

      Character Count: out of 36000
       not selected

   2. If the allowance for the personal needs of a waiver participant with a community spouse is different from the amount used for the individual's maintenance allowance under 42 CFR §435.726 or 42 CFR §435.735, explain why this amount is reasonable to meet the individual's maintenance needs in the community.

      Select one:

       Allowance is the same
       Allowance is different.

      Explanation of difference:

      Character Count: out of 6000

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

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

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

      Select one:

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

Appendix B: Participant Access and Eligibility

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

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

   Answers provided in Appendix B-5-a indicate 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)

6. 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)

7. Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules - 2014 through 2018.

   The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care. There is deducted from the participant's monthly income a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the State Medicaid Plan. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).

   Answers provided in Appendix B-5-a indicate 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

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

   1. Minimum number of services.

      The minimum number of waiver services (one or more) that an individual must require in order to be determined to need waiver services is:
   2. Frequency of services. The State requires (select one):
       The provision of waiver services at least monthly
       Monthly monitoring of the individual when services are furnished on a less than monthly basis

      If the State also requires a minimum frequency for the provision of waiver services other than monthly (e.g., quarterly), specify the frequency:

      Character Count: out of 4000
       not selected
2. Responsibility for Performing Evaluations and Reevaluations. Level of care evaluations and reevaluations are performed (select one):
    Directly by the Medicaid agency
    By the operating agency specified in Appendix A
    By an entity under contract with the Medicaid agency.

   Specify the entity:

   Character Count: out of 4000

   Waiver Case Management agencies contracted with SMA to perform reevaluations of level of care
    Other
   Specify:

   Character Count: out of 4000
    not selected
3. Qualifications of Individuals Performing Initial Evaluation: Per 42 CFR §441.303(c)(1), specify the educational/professional qualifications of individuals who perform the initial evaluation of level of care for waiver applicants:

   Character Count: out of 6000
   Individuals performing the initial level of care evaluation are required to be Registered Nurses or Physicians licensed within the State of Utah.
4. Level of Care Criteria. Fully specify the level of care criteria that are used to evaluate and reevaluate whether an individual needs services through the waiver and that serve as the basis of the State's level of care instrument/tool. Specify the level of care instrument/tool that is employed. State laws, regulations, and policies concerning level of care criteria and the level of care instrument/tool are available to CMS upon request through the Medicaid agency or the operating agency (if applicable), including the instrument/tool utilized.

   Character Count: out of 12000
   Utah State administrative rule R414-502 delineates the nursing facility level of care criteria that must be met to qualify for the Medicaid State Plan nursing facility benefit. In accordance with R414-502, it must be determined whether an applicant has mental or physical conditions that require the level of care provided in a nursing facility, or equivalent care provided through a Medicaid Home and Community-Based Waiver program, by documenting at least two of the following factors exist: (a) Due to diagnosed medical conditions, the applicant requires substantial physical assistance with activities of daily living above the level of verbal prompting supervision or setting up; (b) The attending physician has determined that the applicant’s level of dysfunction in orientation to person, place, or time requires nursing facility care; or equivalent care provided through a Medicaid Home and Community-Based Waiver program; or (c) The medical condition and intensity of services indicate that care need of the applicant cannot be safely met in a less structured setting, or without the services and supports of a Medicaid Home and Community-Based Waiver program.
5. Level of Care Instrument(s). Per 42 CFR §441.303(c)(2), indicate whether the instrument/tool used to evaluate level of care for the waiver differs from the instrument/tool used to evaluate institutional level of care (select one):
    The same instrument is used in determining the level of care for the waiver and for institutional care under the State Plan.
    A different instrument is used to determine the level of care for the waiver than for institutional care under the State plan.

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

   Character Count: out of 12000

   The InterRAI MINIMUM DATA SET- HOME CARE (MDS-HC) serves as the standard comprehensive assessment instrument for this waiver and includes all the data fields necessary to measure the individual’s level of care as defined in the State’s Medicaid nursing facility admission criteria. Persons responsible for collecting the needed information and for making level of care determinations are trained by staff of the SMA in the proper application of the MDS-HC instrument and the proper analysis of the MDS-HC data to perform level of care evaluations
    not selected
6. Process for Level of Care Evaluation/Reevaluation: Per 42 CFR §441.303(c)(1), describe the process for evaluating waiver applicants for their need for the level of care under the waiver. If the reevaluation process differs from the evaluation process, describe the differences:

   Character Count: out of 12000
   Initial level of care screenings and evaluations: 1) For applicants who are currently receiving Medicaid reimbursed nursing facility services on an extended stay basis, and therefore have already had a level of care determination performed by the SMA under the nursing facility admission process, the prior determination will be considered as conditionally meeting the waiver level of care determination requirement. Within fourteen working days of having received a referral, the applicant selected case management provider will validate that the individual continues to meet level of care requirements during the completion of the initial waiver comprehensive needs assessment, using the standard instrument/tool described in Appendix B-6(e). In the event the conditional determination is not validated by the case management provider, the individual will be advised through a written notice of agency action that the waiver eligibility criteria has not been met and offered an opportunity for a fair hearing. 2) For nursing facility applicants who have not had level of care eligibility previously determined through the nursing facility admission process, a Department of Health RN will conduct a review of the standard instrument/tool, medical records and physician orders from the nursing facility to perform the initial level of care screening. Within fourteen working days of having received a referral, the applicant selected case management provider will validate that the individual does meet level of care requirements during the completion of the initial waiver comprehensive needs assessment, using the standard instrument/tool described in Appendix B-6(e). In the event the conditional determination is not validated by the case management provider, the individual will be advised through a written notice of agency action that the waiver eligibility criteria has not been met and offered an opportunity for a fair hearing. 3) For small health care facility applicants and assisted living facility applicants, a Department of Health RN will conduct a review of medical records, service plans, physician orders and other pertinent case history to perform the initial level of care screening. Within fourteen working days of having received a referral, the applicant selected case management provider will validate that the individual does meet level of care requirements during the completion of the initial waiver comprehensive needs assessment, using the standard instrument/tool described in Appendix B-6(e). In the event the conditional determination is not validated by the case management provider, the individual will be advised through a written notice of agency action that the waiver eligibility criteria has not been met and offered an opportunity for a fair hearing. 4) For applicants who are currently receiving care in another of Utah’s 1915(c) waiver programs and therefore have already had a nursing facility level of care determination performed by the designated level of care entity under that waiver’s admission process, the prior determination will be considered as conditionally meeting the waiver level of care determination requirement. Within fourteen working days of having received a referral, the applicant selected NCW case management provider will validate that the individual does meet level of care requirements during the completion of the initial waiver comprehensive needs assessment, using the standard instrument/tool described in Appendix B-6(e). In the event the conditional determination is not validated by the case management provider, the individual will be advised through a written notice of agency action that the waiver eligibility criteria has not been met and offered an opportunity for a fair hearing. 5) For previously enrolled participants who were disenrolled due to long term nursing facility admission or due to receipt of a lump sum settlement that disqualified them from Medicaid benefits, a new level of care reassessment must be performed by the participant’s selected NCW case management agency prior to re-enrollment. Level-of-care reevaluations: The contracted case management provider will validate that the individual continues to meet level of care requirements during the completion of the annual (at a minimum) comprehensive reassessment of the participant’s needs, using the standard instrument/tool described in Appendix B-6(e), (MDS-HC). In the event the reevaluation indicates the participant no longer meets nursing facility level of care, the case management provider will contact a Department of Health RN to request a review of the standard level of care instrument/tool. If the Department of Health RN concurs that the participant no longer meets the nursing facility admission criteria, the individual will be advised through a written notice of agency action that the waiver eligibility criteria has not been met and offered an opportunity for a fair hearing. The contracted case management provider will be required to maintain original records of all completed MDS-HCs. Copies of MDS-HCs must be made available to the Bureau of Authorization and Community Based Services, Department of Health, upon request. Records will be reviewed as a component of the quality assurance monitoring completed by the SMA.
7. Reevaluation Schedule. Per 42 CFR §441.303(c)(4), reevaluations of the level of care required by a participant are conducted no less frequently than annually according to the following schedule (select one):
    Every three months
    Every six months
    Every twelve months
    Other schedule
   Specify the other schedule:

   Character Count: out of 4000

   A full level of care reevaluation will be completed at a minimum of annually (no later than by the end of the same calendar month of the last level of care evaluation, one year later). Health status screenings must be performed by the case management provider’s RN any time a participant has experienced a substantial change in health status and at the conclusion of all inpatient stays in a medical institution to determine whether the participant’s health status indicates: a. needs can continue to be safely met within the waiver program, and b. the participant continues to meet nursing facility level of care. If during the health status screening it becomes evident that the participant’s mental or physical condition has changed substantially, a new full level of care re-evaluation must be performed.
    not selected
8. Qualifications of Individuals Who Perform Reevaluations. Specify the qualifications of individuals who perform reevaluations (select one):
    The qualifications of individuals who perform reevaluations are the same as individuals who perform initial evaluations.
    The qualifications are different.
   Specify the qualifications:

   Character Count: out of 6000
    not selected
9. Procedures to Ensure Timely Reevaluations. Per 42 CFR §441.303(c)(4), specify the procedures that the State employs to ensure timely reevaluations of level of care (specify):

   Character Count: out of 6000
   The level of care reevaluation and tracking process will be included as a standard requirement for all case management providers enrolled as waiver providers. Case management providers will be required to develop and maintain a tracking system to insure that reevaluations occur in a timely manner. Timeliness of reevaluations will periodically be reviewed by the SMA as part of the SMA quality assurance program.
10. Maintenance of Evaluation/Reevaluation Records. Per 42 CFR §441.303(c)(3), the State assures that written and/or electronically retrievable documentation of all evaluations and reevaluations are maintained for a minimum period of 3 years as required in 45 CFR §92.42. Specify the location(s) where records of evaluations and reevaluations of level of care are maintained:

    Character Count: out of 6000
    The case management providers are required to maintain records of level of care evaluations and reevaluations in the participant’s waiver case record.

Appendix B: Evaluation/Reevaluation of Level of Care

Quality Improvement: Level of Care

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

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

   1. Sub-Assurances:

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

         Performance Measures

         For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

         Performance Measure: The number and percentage of initial screenings for level of care that are conducted for applicants who meet New Choices Waiver guidelines for enrollment. (N = # of screenings completed; D = total # of screenings required). Data Source (Select one): Other If 'Other' is selected, specify: SMA New Choices Waiver Unit Applciation Records Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: The number and percentage of new participants who are admitted to the New Choices Waiver that meet nursing facility LOC. (N = # of participants who met level of care; D = total # of new participants). Data Source (Select one): Other If 'Other' is selected, specify: LOC determination form and MDS-HC Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

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

         Performance Measures

         For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

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

         Performance Measures

         For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

         Performance Measure: The number and percentage of participants, for whom the Level of Care Determination Form accurately documents the LOC criteria based on the MDS-HC assessment. (N = # of determinations in compliance; D = total # of LoC determinations) Data Source (Select one): Other If 'Other' is selected, specify: LOC determination forms, MDS-HC, Participant Records Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: The number and percentage of new enrollees for whom the Form 927, Home and Community-Based Waiver Referral Form documented the effective date of the applicant’s Medicaid eligibility determination and the effective date of the applicant’s level of care eligibility determination. (N = # of completed 927's; D = total # of 927's required) Data Source (Select one): Other If 'Other' is selected, specify: Participant records, Form 927 Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: The number and percentage of participants for whom an assessment for level of care was conducted by a qualified registered nurse or physician licensed in the state. (N = # of assessments in compliance; D = total # of assessments) Data Source (Select one): Other If 'Other' is selected, specify: MDS-HC Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

   2. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
      Character Count: out of 6000
      All individuals who apply for New Choices Waiver services and who meet minimum requirements are evaluated by an R.N. using the Minimum Data Set for Home Care (MDS-HC) tool to determine if the applicant meets nursing facility level of care. For Initial Level of Care Determinations: The general requirements of this waiver provide upfront fail-safe mechanisms for assuring level of care determinations are completed by qualified individuals for all new entrants into the waiver. Applicants from a nursing facility on a Medicaid reimbursed stay are determined to meet level of care criteria by the Utah Department of Health registered nurses who perform this task for all Medicaid nursing facility admissions. Prior to initiating admission to the NCW, the SMA NCW Unit must verify that the Utah Department of Health registered nurses found the applicant to meet long term care criteria for nursing facility care. Applicants in a skilled nursing facility on a Medicare reimbursed stay or on a hospice stay are not assessed the same way as those on a Medicaid reimbursed stay in a nursing facility. Medicare reimbursed residents and hospice patients will be screened for nursing facility level of care by a Utah Department of Health RN using the standard level of care instrument/tool, medical records and physician orders from the nursing facility. Applicants from a small health care facility (Type N) or from a licensed assisted living facility have not had a level of care evaluation prior to the time of NCW application because these types of facilities are not required to perform nursing facility level of care evaluations as a condition to admit private pay individuals. For each NCW applicant from a small health care facility or from an assisted living facility, the initial nursing facility level of care screening is performed by a Utah Department of Health RN who will conduct a review of medical records, service plans, physician orders and other pertinent case history from the facility. This assures that 100% of the cases meet the requirement “LOC was conducted by a qualified registered nurse or physician licensed in the state.” In addition, to confirm that the level of care criteria is met following the screening by the Department of Health RN, the New Choices Waiver case management registered nurses complete a MDS-HC prior to enrollment in the waiver. This documentation is required to be submitted to the SMA NCW Unit by the case management agency prior to the applicant’s enrollment in the program. Applicants are not enrolled into the program without this documentation. For Level of Care Re-evaluation Determinations: Annually at a minimum, case management providers are required to submit level of care re-determinations and updated care plans. Annual care plans will not be authorized without receiving the written evidence that an annual level of care re-evaluation has been completed and the participant continues to meet nursing facility level of care. The written evidence must be completed by the registered nurse or physician who performed the annual level of care re-evaluation. The SMA NCW Unit tracks level-of care determinations and redeterminations completed and by whom the determinations were made. The SMA NCW Unit then reports the information to the SMA QA Unit on an annual basis. The SMA QA Unit will review the annual report and determine if the performance measure has been met. In the event the SMA QA Unit determines the performance measure has not been met, the SMA NCW Unit will develop and implement an approved corrective action or quality improvement initiative. The SMA NCW Unit conducts an annual review of the New Choices Waiver program for each of the five waiver years. At a minimum, one comprehensive review will be conducted involving the SMA QA Unit during this five year cycle. The SMA QA Unit has the discretion to perform ad hoc focused reviews as well. 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.
2. Methods for Remediation/Fixing Individual Problems
   1. Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.
      Character Count: out of 6000
      Individual issues identified 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.
   2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)

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

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

    No

    Yes

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

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

B-7: Freedom of Choice

1. Procedures. Specify the State's procedures for informing eligible individuals (or their legal representatives) of the feasible alternatives available under the waiver and allowing these individuals to choose either institutional or waiver services. Identify the form(s) that are employed to document freedom of choice. The form or forms are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
   Character Count: out of 12000
   1. The SMA NCW Unit will include a waiver fact sheet with all NCW applications that are sent to interested applicants. The waiver fact sheet provides a complete listing of all services available within the New Choices Waiver program. 2. As part of the application process, the applicant or the applicant’s legal representative completes and signs the Freedom of Choice Consent Form which is designed to: a. Inform the applicant of any feasible alternatives under the waiver; and b. Offer the choice of either institutional or home and community-based services. 3. The individual is informed that the State Medicaid Agency provides an opportunity for a fair hearing, under 42 CFR Part 431, subpart E, to individuals who are not given the choice of home or community-based services as an alternative to nursing facility institutional care.
2. Maintenance of Forms. Per 45 CFR §92.42, written copies or electronically retrievable facsimiles of Freedom of Choice forms are maintained for a minimum of three years. Specify the locations where copies of these forms are maintained.
   Character Count: out of 4000
   Freedom of Choice Consent forms will be maintained in the participant’s waiver case record maintained by the case management provider and also in the records maintained by the SMA NCW Unit.

Appendix B: Participant Access and Eligibility

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

Appendix C: Participant Services

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

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

   Service Type	Service
   Statutory Service	Adult Day Care
   Statutory Service	Case Management
   Statutory Service	Habilitation
   Statutory Service	Homemaker
   Statutory Service	Respite
   Extended State Plan Service	Supportive Maintenance Services
   Supports for Participant Direction	Consumer Preparation Services
   Supports for Participant Direction	Financial Management Services
   Other Service	Adult Residential Services
   Other Service	Assistive Technology Devices
   Other Service	Attendant Care Services
   Other Service	Caregiver Training
   Other Service	Chore Services
   Other Service	Community Transition Services
   Other Service	Environmental Accessibility Adaptations
   Other Service	Home Delivered Meals
   Other Service	Medication Administration Assistance Services
   Other Service	Personal Budget Assistance
   Other Service	Personal Emergency Response System
   Other Service	Specialized Medical Equipment, Supplies and Supplements
   Other Service	Transportation - Non-Medical