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):

   Physical Disabilities 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.0331
   Waiver Number:UT.0331.R04.00
   Draft ID:UT.015.04.00
4. Type of Waiver (select only one):
   Model Waiver Regular Waiver
5. Proposed Effective Date: (mm/dd/yy)
   Approved Effective Date: 07/01/16

1. Request Information (2 of 3)

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

    Hospital as defined in 42 CFR §440.10

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

   Character Count: out of 6000

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

    not selected
   Nursing Facility
   Select applicable level of care

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

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

   Character Count: out of 6000

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

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

   Character Count: out of 6000

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
   In the process of drafting this renewal application, the SMA convened a workgroup comprised of advocates, providers, participant family members and staff from both the Bureau of Authorization and Community Based Services, Utah Department of Health, and the Division of Services for People with Disabilities (DSPD), Department of Human Services. The workgroup convened as part of the drafting process participated in four workgroup sessions. Utilizing feedback from the group, proposed changes were implemented into a draft renewal application. Additionally, feedback from DSPD’s PD Waiver survey known as the Tour de Utah was also considered by the workgroup when drafting the renewal application. The Tour de Utah is a survey geared to identify additional needs of the PD Waiver population. As needs are identified, the survey is designed to help guide the PD Waiver program in considering policy changes to enhance the array of available service options accessible through the PD Waiver. The State met with both the Utah Indian Health Advisory Board (UIHAB) and the Utah Centers for Independent Living (CILs) in March of 2016 to discuss proposed changes to the PD Waiver previously sent to them and to obtain their feedback for incorporation into the proposed PD Waiver renewal application. The Medical Care Advisory Committee (MCAC), Employment Partnership (EP) and Disability Advisory Council (DAC) were also notified of the upcoming renewal application in February of 2016. On February 12, 2016, the full draft renewal application was sent to a wide network of providers, consumers, governmental entities and other interested parties including the UIHAB, CILs, MCAC, EP, DAC, Disability Law Center, Utah Legislative Coalition, Utah Statewide Independent Living Council and the Utah Developmental Disabilities Council for review. The proposed renewal application was also posted on the SMA’s website at http://www.health.utah.gov/ltc. Notification was also published in the newspaper to help make the public aware of the application and how to submit public comment. Comment was accepted through March 25, 2016. Only one comment was received and pertained to the age requirement for personal attendants. The public comment received requested that the State consider allowing waiver participants to hire minors (at least 16 years of age) to provide care as Personal Attendants. Currently the requirement for providers is that they are at least 18 years of age. The State recognizes that this may be of benefit of some participants but does believe that the current standard is best suited for the overall waiver population due to the extent of services that Personal Attendants may be responsible to provide.

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

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

7. Contact Person(s)

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

   First Name:

   Title:

   Agency:

   Address:

   Address 2:

   City:

   State:

   Utah

   Zip:

   Phone:

   Ext: TTY

   Fax:

   E-mail:

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

   First Name:

   Title:

   Agency:

   Address:

   Address 2:

   City:

   State:

   Utah

   Zip:

   Phone:

   Ext: TTY

   Fax:

   E-mail:

8. Authorizing Signature

Attachments

Specify the transition plan for the waiver:

Additional Needed Information (Optional)

Appendix A: Waiver Administration and Operation

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

    The waiver is operated by the State Medicaid agency.

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

    The Medical Assistance Unit.

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

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

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

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

   Specify the division/unit name:The Division of Services for People with Disabilities (DSPD)

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

    not selected

Appendix A: Waiver Administration and Operation

2. Oversight of Performance.

   1. Medicaid Director Oversight of Performance When the Waiver is Operated by another Division/Unit within the State Medicaid Agency. When the waiver is operated by another division/administration within the umbrella agency designated as the Single State Medicaid Agency. Specify (a) the functions performed by that division/administration (i.e., the Developmental Disabilities Administration within the Single State Medicaid Agency), (b) the document utilized to outline the roles and responsibilities related to waiver operation, and (c) the methods that are employed by the designated State Medicaid Director (in some instances, the head of umbrella agency) in the oversight of these activities:
      As indicated in section 1 of this appendix, the waiver is not operated by another division/unit within the State Medicaid agency. Thus this section does not need to be completed.
      Character Count: out of 12000
   2. Medicaid Agency Oversight of Operating Agency Performance. When the waiver is not operated by the Medicaid agency, specify the functions that are expressly delegated through a memorandum of understanding (MOU) or other written document, and indicate the frequency of review and update for that document. Specify the methods that the Medicaid agency uses to ensure that the operating agency performs its assigned waiver operational and administrative functions in accordance with waiver requirements. Also specify the frequency of Medicaid agency assessment of operating agency performance:
      Character Count: out of 12000
      The Home and Community Based Services Waiver-Division of Services for People with Disabilities Interagency Agreement (Interagency Agreement) between the State Medicaid Agency (SMA) and DSPD sets forth the respective responsibilities for the administration and operation of the PD Waiver. This Interagency Agreement runs for a five year period, but can be amended as needed. The Interagency Agreement delineates the SMA's overall responsibility to provide management and oversight of the PD Waiver, as well as DSPD's operational and administrative functions. The responsibilities of DSPD as the Operating Agency (OA) are delegated as follows. Most of these responsibilities are shared with the SMA: 1. Program Development 2. Rate Setting and Fiscal Accountability 3. Program Coordination, Education and Outreach 4. HCBS Waiver Staffing Assurances 5. Eligibility Determination and Waiver Participation Assurances 6. Waiver Participant Involvement in Decision Making 7. Hearings and Appeals 8. Monitoring, Quality Management and Quality Improvement 9. Reporting 10. Data Security The SMA monitors the Interagency Agreement through a series of quality assurance activities, provides ongoing technical assistance and reviews and approves all rules, regulations and policies that govern PD Waiver operations. There is a focused program review conducted annually by the SMA Quality Assurance Team. If ongoing or focused annual reviews conducted by the SMA Quality Assurance Team reveal concerns with compliance, DSPD is required to develop plans of correction within specific time frames to correct the problems. The SMA Quality Assurance Team conducts follow up activities to ensure that corrections are sustaining.

Appendix A: Waiver Administration and Operation

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

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

Appendix A: Waiver Administration and Operation

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

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

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

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

   Character Count: out of 6000

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

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

   Character Count: out of 6000

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

Appendix A: Waiver Administration and Operation

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

Appendix A: Waiver Administration and Operation

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

Appendix A: Waiver Administration and Operation

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

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

Appendix A: Waiver Administration and Operation

Quality Improvement: Administrative Authority of the Single State Medicaid Agency

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

   1. Performance Measures

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

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

      Where possible, include numerator/denominator.

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

      Performance Measure: Number and percentage of OA annual reports specified in the implementation plan that were submitted to the SMA on time and in the correct format. The numerator is the number of reports submitted to the SMA by the OA in the proper format and within required timeframes; the denominator is the total number of all reports submitted to the SMA by the OA. Data Source (Select one): Other If 'Other' is selected, specify: DSPD Annual reports and DSPD Annual Incident report Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percentage of participants who have been denied access to the Medicaid waiver program, who were provided timely notice of appeal rights. The numerator is the total number of participants who were denied and received a timely notice of appeal rights; the denominator includes these individuals along with those who may have been denied but did not receive a timely notice. Data Source (Select one): Other If 'Other' is selected, specify: The Utah Systems for Tracking Eligibility, Planning and Services (USTEPS) Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: # and percentage % of participants who have a) had a reduction/denial of a waiver service; b) been denied choice of provider if more than one was available; or c) been determined ineligible when previously receiving services, who were provided timely notice of appeal rights. N = # of compliant cases in compliance; D = total # of cases with or without timely notification requiring notification. Data Source (Select one): Other If 'Other' is selected, specify: USTEPS Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 95% Confidence Level, 5% Margin of Error Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percentage of documents submitted to and approved by the SMA using the Document Submittal Protocol prior to implementation. The numerator is the total number of documents that were appropriately submitted by the OA; the denominator includes both documents that were correctly submitted and any documents that were not correctly submitted for SMA review prior to implementation. Data Source (Select one): Other If 'Other' is selected, specify: Document Approval forms and DSPD documents Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percentage of maximum allowable rates (MARs) for covered Waiver services approved by the SMA. The numerator is the total number of service codes for which the SMA has approved the payment rate prior to their use; the denominator is the total number of MARs allowed in the program. Data Source (Select one): Other If 'Other' is selected, specify: Rate setting meetings minutes, Approval documentation and Correspondence Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

   2. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
      Character Count: out of 6000
      The SMA demonstrates ultimate administrative authority and responsibility for the operation of the PD Waiver program through numerous activities including the issuance of policies, rules and regulations relating to the PD Waiver as well as the review and approval of protocols, documents, provider manuals including the PD Waiver provider manual, bulletins, rates and trainings that affect any aspect of PD Waiver operations. The SMA also conducts quarterly meetings with DSPD staff, monitors compliance with the Interagency Agreement, conducts focused annual quality assurance reviews of the PD Waiver program and provides technical assistance to DSPD and other entities within the state that affect the operation of the PD Waiver program. The SMA verifies compliance with the Administrative Authority performance measures at least annually. The SMA is the entity responsible for official communication with CMS for all issues related to the PD Waiver.
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. These issues are addressed in a variety of ways, and may include: a) direct contact for additional information if any, and b) informal discussion or formal (written) notice of adverse findings. The SMA will use discretion in determining notice requirements depending on the findings. Examples of issues requiring intervention by the SMA would include: overpayments; allegations or substantiated violations of health and safety; necessary involvement of APS and/or local law enforcement; or issues involving the State’s Medicaid Fraud Control Unit. To assure the issue has been addressed, DSPD is required to report back to the SMA on the results of their interventions within designated time frames. These time frames are outlined in standard operating procedures or protocols or are stipulated on a case by case basis depending on the nature of a specific issue. A description of issues requiring immediate attention and outcomes are documented through the SMA Final Report (Final Report). Issues that are less immediate are corrected within designated time frames and are also documented through the Final Report. When the SMA 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 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
   The individual must: 1) Have established programmatic eligibility through the Utah Department of Human Services for state matching funds in accordance with Utah Code Annotated (UCA) § 62A-51 and Utah Administrative Code (UAC) R539-1-6 by meeting the following criteria: a) Have at least one personal attendant trained (or willing to be trained) and available to provide the authorized PD Waiver services in a residence that is safe and can accommodate the personnel and equipment (if any) needed to adequately and safely care for the individual. DSPD will provide information to the individual about potential community resources to assist them in recruiting an attendant. b) Be medically stable, have a physical disability which the physician expects to last for a continuous period of not less than 12 months and which has resulted in the individual’s functional loss of two or more limbs. c) Have decision making capability* to select, train and supervise their personal attendant(s) as certified by a physician. d) Have decision making capability* to manage their own financial and legal affairs. 2) If a person is eligible for more than one of the waivers operated by DSPD, DSPD will educate the individual about their choices and advise them which of the waivers may best meet their needs. * Individuals possessing decision making capability but having communication deficits or limited English proficiency may select a representative to communicate decisions on the individual’s behalf.

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

   Clients age from the Disabled (Physical) to the Aged (age 65 and older) target group/subgroup.

Appendix B: Participant Access and Eligibility

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

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

   The limit specified by the State is (select one)

    A level higher than 100% of the institutional average.

   Specify the percentage:

    Other

   Specify:

   Character Count: out of 6000

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

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

   Character Count: out of 6000

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

    The following dollar amount:

   Specify dollar amount:

   The dollar amount (select one)

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

   Specify the formula:

   Character Count: out of 6000

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

    not selected

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

   Specify percent:

    Other:

   Specify:

   Character Count: out of 6000

    not selected
    not selected

Appendix B: Participant Access and Eligibility

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

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

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

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

   Character Count: out of 12000
   Other safeguard(s)

   Specify:

   Character Count: out of 12000

Appendix B: Participant Access and Eligibility

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

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

   Table: B-3-a

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

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

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

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

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

   Table: B-3-b

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

Appendix B: Participant Access and Eligibility

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

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

   Not applicable. The state does not reserve capacity.

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

Appendix B: Participant Access and Eligibility

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

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

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

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

5. Allocation of Waiver Capacity.

   Select one:

   Waiver capacity is allocated/managed on a statewide basis.

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

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

   Character Count: out of 12000
6. Selection of Entrants to the Waiver. Specify the policies that apply to the selection of individuals for entrance to the waiver:
   Character Count: out of 12000
   Medicaid recipients who meet the programmatic eligibility requirements as defined in Appendix B-1 are given a choice to either receive services in a Nursing Facility (NF) or through the PD Waiver. The applicant’s choice will be documented in writing, signed by the applicant and maintained as part of the individual record in the Utah Systems for Tracking Eligibility, Planning and Services (USTEPS). If available capacity exists, individuals may enroll in the PD Waiver. If no available capacity exists in the PD Waiver, the applicant will be advised in writing that he or she may access services through a NF or may wait for open capacity to develop in the PD Waiver. If the individual chooses to wait for open capacity, DSPD provides information about community resources to assist the individual. In addition, if the individual is currently Medicaid eligible, they have access to Medicaid State Plan services. The State has developed policies prioritizing access to individuals waiting for waiver services. These policies provide opportunities for access to individuals residing in the community and in institutional settings. DSPD has established a Critical Needs Assessment process by which individuals are ranked to prioritize access to waiver services. A significant component of the Critical Needs Assessment tool addresses the immediacy of the need for services and the individual’s risk in not gaining access to waiver services. Individuals in nursing facilities do not demonstrate an immediate need for services, nor do they present as being at high risk if waiver services are not extended to them. Individuals in institutional facilities rank extremely low on the prioritization for receipt of waiver services. The State recognized this problem and initiated a separate process in which individuals in institutional settings may gain access to waiver services. Medicaid recipients residing in nursing facilities, meeting the PD Waiver criteria may gain access to the PD Waiver by having the State general funds, that supported the person in the NF, follow the person into the PD Waiver, i.e., the money-follows-the-person concept. The State believes the existence of these two access points of admission into the PD Waiver is an equitable methodology to support access from both the institution and the community. This methodology is supported by the State’s Olmstead Advisory Committee and has not resulted in growth of the NF program. The State has chosen to not reserve capacity to accommodate both points of entry. The individual tracks do not take priority over each other as each track has its own funding process. Once a person in institutional care (i.e., NF) is ready to transition from the NF and is found eligible to receive services through the PD Waiver, as long as the number of unduplicated participants authorized in the waiver has not been exceeded, the person may begin receiving services. A person who lives in the community with physical disabilities and who has an immediate need for services is placed on the waiting list. Once the Utah State Legislature provides an allocation, those waiting with the greatest criticality receive funding first until the allocation is expended.

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
   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. 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
       Other

      Specify:

      Character Count: out of 6000
       not selected

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

       Not Applicable (see instructions)
       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

   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
       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).

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

Appendix B: Participant Access and Eligibility

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

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

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

   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
       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
       not selected

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).

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

   Character Count: out of 12000
   Utah Administrative Code R414-502 defines the State’s level of care for NF care. The rule defines that a client must meet two of the following three criteria (specifically criteria 1 and 3 below for participants of the PD Waiver): (1) Due to diagnosed medical conditions, the applicant requires substantial physical assistance with daily living activities above the level of verbal prompting, supervising, or setting up; (2) 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 (3) The medical condition and intensity of services indicate that the care needs 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. DSPD will conduct evaluation and reevaluation assessments using the standard waiver instrument, InterRAI MINIMUM DATA SET – HOME CARE (MDS-HC) as described in Appendix B-6(e), to assess level of care.
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) is the instrument used to determine the level of care for this waiver. Persons responsible for collecting the needed information and for making level of care determinations are staff from DSPD trained in the proper application of the MDS-HC instrument and the proper analysis of the MDS-HC data to perform level of care evaluations. The MDS-HC is a comprehensive, standardized instrument for evaluating the needs, strengths and preferences of clients served by home care agencies. The MDS-HC also acts as a screening component that enables a home care provider to assess multiple key domains of function, health, social support and service use. Particular MDS-HC items identify clients who could benefit from further evaluation of specific problems and risk for functional decline. The MDS-HC has been designed to be compatible with the family of InterRAI assessment and problem identification tools which includes the MDS (InterRAI Minimum Data Set) nursing home assessment instrument. Such compatibility promotes continuity of care through a seamless geriatric assessment system across multiple health care settings and promotes a person-centered evaluation in contradiction to a site-specific assessment. Accordingly, the main differences between the MDS-HC and the MDS is that the MDS includes assessment information more pertinent to a residential facility setting, addressing structural problems related to performance of ADLs (Activities of Daily Living) in a facility, activity pursuit patterns, discharge potential and overall status and therapy supplement. Whereas the MDS-HC includes assessment information more pertinent to community living by addressing social functioning, informal support services, preventative health measures, environmental assessment, service utilization of home care services, medications (prescription, non-prescription and herbal), resource/support and services assessment and information, social resource assessment, caregiver assessment, social support information, additional medical problems and nurse summary sections. Despite these differences, both the MDS-HC and MDS assessments help to determine level of care by including basic assessment data related to the individual. This information includes: identification and background information, cognitive patterns, communication/hearing patterns, vision patterns, mood and behavior patterns, physical functioning [Instrumental Activities of Daily Living (IADLs) and ADLs performance], continence, disease diagnoses, health conditions, nutrition/hydration status, skin condition, special treatments and therapies and programs.
    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
   DSPD utilizes the following process to make level of care determinations as follows: The registered nurse employed by DSPD will conduct a face to face level of care assessment using the standard waiver instrument described in Appendix B-6(e). This assessment is conducted at the individual’s current living environment.
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 calendar month of the last level of care evaluation, one year later). A Health Status Screening must be performed (either by phone or in person) by the administrative case manager at any time a participant has experienced a significant 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 that: 1) The participant’s needs can continue to be safely met within the scope of the PD Waiver program; and 2) The participant continues to meet NF level of care. If during the Health Status Screening it becomes evident that the participant’s mental or physical condition has changed significantly, a new level of care reevaluation must be performed in person. The administrative case manager will document the Health Status Screening date and determination in the participant’s activity log in USTEPS.
    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
   USTEPS, developed and maintained by DSPD, creates an automated tickler “to do” message that is sent at the beginning of the month in which a reevaluation is due.
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
    Electronically retrievable documentation of all evaluations and reevaluations are maintained within USTEPS. To assure documents are retrievable, standard data back-up procedures employed within the UTSTEPS database include: • The DSPD_USTEPS_PROD_DB is backed up from Sybase database to a disk dump at 10:30 PM every night. The Uniplexed Information and Computing System (UNIX) backup occurs on the following schedule (these are backups to tape): • Monthly Full on 1st of each month, copies are retained on and off site for 3 years.

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: Number and percentage of new participants admitted to the PD Waiver that have been determined to meet NF Level of Care (LOC) prior to admission to the waiver. Numerator = the number of new participants that were determined to meet NF LOC prior to admission to the waiver; Denominator = the total number of new participants admitted to the waiver. Data Source (Select one): Other If 'Other' is selected, specify: USTEPS Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

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

         Performance Measures

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

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

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

         Performance Measures

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

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

         Performance Measure: Number and percentage of Health Status Screenings conducted when a significant change in health status occurs and/or at the conclusion of an inpatient stay in a medical institution to determine an ongoing need for NF LOC. The numerator is the number of events in compliance; the denominator is the total number of events requiring a Health Status Screening. Data Source (Select one): Other If 'Other' is selected, specify: USTEPS Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 95% Confidence Level, 5% Margin of Error Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: Number and percentage of events when a LOC is re-evaluated at the time a significant change in health status occurs to determine if the individual continues to meet NF LOC, when the Screening dictates one was required. The numerator is the number of events in compliance; the denominator is the total number of events that occurred during the review period. Data Source (Select one): Other If 'Other' is selected, specify: USTEPS Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 95% Confidence Level, 5% Margin of Error Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: Number and percentage of LOC initial evaluations and reevaluations conducted by a licensed Utah Registered Nurse (RN). The numerator is the number of LOC initial evaluations and reevaluations which were performed by a licensed Utah RN; the denominator is the total number of LOC initial evaluations and reevaluations performed and reviewed. Data Source (Select one): Other If 'Other' is selected, specify: USTEPS Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 95% Confidence Level, 5% Margin of Error Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: Number and percentage of LOC reevaluations conducted during a face to face visit. The numerator is the number of LOC reevaluations that were conducted during a face to face visit with the participant; the denominator is the total number of LOC re evaluations reviewed. Data Source (Select one): Other If 'Other' is selected, specify: USTEPS Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 95% Confidence Level, 5% Margin of Error Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: Number and percentage of participants for whom the Level of Care Determination Form accurately documents the LOC criteria based on the MDS-HC assessment. (Numerator = # of LOC forms correctly documenting LOC criteria; Denominator = total # of LOC forms completed). Data Source (Select one): Other If 'Other' is selected, specify: Participant Records/USTEPS Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 95% Confidence Level, 5% Margin of Error Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis(check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

   2. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
      Character Count: out of 6000
      Individuals who request services from DSPD through the PD Waiver are screened for level of care and then ranked according to a critical needs assessment process and placed on the waiting list. When the individual is taken off of the waiting list, the administrative case manager determines if the individual needs services from the PD Waiver program. For all individuals who have been taken off of the waiting list and require services, an evaluation for level of care is conducted by the administrative case manager. DSPD is the entity that will conduct level of care reviews. Issues regarding the accuracy of level of care determinations are addressed and corrected immediately by DSPD.
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 regarding the accuracy of level of care determination are addressed and corrected immediately by DSPD to assure that all participants meet NF level of care. Plans of correction which include additional training may be required to assure future compliance. To assure all issues have been addressed, DSPD is required to report back to the SMA on the results of their interventions within the time frame stipulated in standard operating procedures and protocols or are stipulated on a case by case basis depending on the nature of a specific issue. Results of the reviews will be documented in the SMA Final Report.
   2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)

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

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

    No

    Yes

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

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

B-7: Freedom of Choice

1. Procedures. Specify the State's procedures for informing eligible individuals (or their legal representatives) of the feasible alternatives available under the waiver and allowing these individuals to choose either institutional or waiver services. Identify the form(s) that are employed to document freedom of choice. The form or forms are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
   Character Count: out of 12000
   Freedom of Choice is documented in the Person Centered Support Plan (PCSP). Freedom of choice procedures: 1. When an individual is determined eligible for waiver services, the individual and the individual’s representative, if applicable, will be informed of the alternatives available under the waiver programs and offered the choice of institutional care (NF) or home and community-based care. A copy of the DSPD publication AN INTRODUCTORY GUIDE-Division of Services for People with Disabilities (Guide), which describes the array of services and supports available in Utah including NFs and the HCBS waiver programs, is given to each individual applying for waiver services. 2. The administrative case manager will offer the choice of waiver services only if: a. The individual's needs assessment indicates the services the individual requires, including waiver services, are available in the community. b. The individual support plan has been agreed to by all parties. c. The health and safety of the individual can be adequately protected in relation to the delivery of waiver services and supports. 3. Once the individual has chosen home and community-based waiver services, the choice has been documented by the administrative case manager and the individual has received a copy of the Guide, subsequent review of choice of program will only be required at the time a substantial change in the enrollee’s condition results in a change in the PCSP. It is, however, the individual’s option to choose institutional (NF) care at any time during the period they are in the waiver. 4. The waiver enrollee will be given the opportunity to choose the providers of waiver services identified on the PCSP if more than one qualified provider is available to render the services. The individual’s choice of providers will be documented in the PCSP. 5. The agency will provide an opportunity for a fair hearing in writing, under 42 CFR Part 431, subpart E, to beneficiaries who are not given the choice of home or community-based services as an alternative to the institutional care specified for this request, who are denied the waiver service(s) and/or waiver provider(s) of their choice, who are found ineligible for a waiver program or who have been notified of actions to suspend, reduce and/or terminate services.
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 is documented in the PCSP as part of the person centered support planning process and is maintained electronically by DSPD in the individual’s case record within USTEPS.

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	Personal Attendant Services
   Supports for Participant Direction	Financial Management Services
   Other Service	Personal Emergency Response Systems (PERS)
   Other Service	Specialized Medical Equipment and Supplies – Monthly Fee
   Other Service	Specialized Medical Equipment and Supplies – Purchase, Installation, Removal, Replacement and Repair