Source: http://hestories.info/application-for-a-1915-c-hcbs-waiver-submitted-by.html?page=21
Timestamp: 2018-11-19 07:01:03
Document Index: 75187075

Matched Legal Cases: ['§447', '§447', '§447', '§447', '§447', '§447']

Participants Subject to Co-pay Charges for Waiver Services
Participants Subject to Co-pay Charges for Waiver Services. Specify the groups of waiver participants who are subject to charges for the waiver services specified in Item I-7-b-iii and the groups for whom such charges are excluded. The groups of participants who are excluded must comply with 42 CFR §447.53.
iii. Amount of Co-Pay Charges for Waiver Services. In the following table, list the waiver services for which a charge is made, the amount of the charge, and the basis for determining the charge. The amount of the charge must comply with the maximum amounts set forth in 42 CFR §447.54.
All services authorized would be included with consumer participation amount
iv. Cumulative Maximum Charges. Indicate whether there is a cumulative maximum amount for all co-payment charges to a waiver participant (select one):
There is no cumulative maximum for all deductible, coinsurance or co-payment charges to a waiver participant.
There is a cumulative maximum for all deductible, coinsurance or co-payment charges to a waiver participant. Specify the cumulative maximum and the time period to which the maximum applies:
v. Assurance. In accordance with 42 CFR §447.53(e), the State assures that no provider may deny waiver services to an individual who is eligible for the services on account of the individual's inability to pay a cost-sharing charge for a waiver service.
b. Other State Requirement for Cost Sharing. Specify whether the State imposes a premium, enrollment fee or similar cost sharing on waiver participants as provided in 42 CFR §447.50. Select one:
No. The State does not impose a premium, enrollment fee, or similar cost-sharing arrangement on waiver participants.
Yes. The State imposes a premium, enrollment fee or similar cost-sharing arrangement. Describe in detail the cost sharing arrangement, including: (a) the type of cost sharing (e.g., premium, enrollment fee); (b) the amount of charge and how the amount of the charge is related to total gross family income as set forth in 42 CFR §447.52; (c) the groups of participants subject to cost-sharing and the groups who are excluded (groups of participants who are excluded must comply with 42 CFR §447.53); and, (d) the mechanisms for the collection of cost-sharing and reporting the amount collected on the CMS 64:
Appendix J-1: Composite Overview and Demonstration
of Cost-Neutrality Formula
Composite Overview. Complete the following table for each year of the waiver. If there is more than one level of care specified in the waiver, complete a separate additional table for each and include a table that reflects the weighted average of the combined levels of care offered in the program.
Level of Care (1) (specify):
Factor D′
Factor G′
G+G′
(Column 7 less Column 4)
Level of Care (2) (specify):
Appendix J-2 - Derivation of Estimates
a. Number Of Unduplicated Participants Served. As specified in Appendix B-2, the following table shows the maximum number of unduplicated participants who will be served each year that the waiver is in operation:
Table: J-2-a
b. Phase-In/Phase-Out Schedule. Indicate whether the waiver is being phased-in or phased-out (select one):
The waiver is being phased-in or phased-out. Attachment #1 to Appendix J-2 specifies the phase-in or phase-out schedule.
c. Average Length of Stay. Describe the basis of the estimate of the average length of stay on the waiver by participants in item J-2-e.
Estimate based on the 372 reports
d. Derivation of Estimates for Each Factor. Provide a narrative description for the derivation of the estimates of the following factors.
i. Factor D Derivation. The estimates of Factor D for each waiver year are located in Item J-2-e. The basis for these estimates is as follows:
Unduplicated # of users for each service was based on the number of recipients from the previous 372 when the waiver was renewed July 2003, an increase by 17% was added to unduplicated users for each year. The average annual number of units per recipients for each services was based on the expenditures from the 372 divided by the rate for reach service to obtain the total number of unites used, this was then divided by the number of recipients to obtain the average number of units used per recipient. The average unit costs includes and increase of 3%
ii. Factor D′ Derivation. The estimates of Factor D’ for each waiver year are included in
Item J-1. The basis of these estimates is as follows:
D” calculations assume a 5% increase. This comes from the MMIS system for other paid Medicaid services
iii. Factor G Derivation. The estimates of Factor G for each waiver year are included in Item J-1. The basis of these estimates is as follows:
These estimates from actual paid claims and the 372 report
iv. Factor G′ Derivation. The estimates of Factor G’ for each waiver year are included in Item J-1. The basis of these estimates is as follows:
Actual paid claims and number of recipients, with a 5% increase each year
e. Estimate of Factor D. Complete the following table for each waiver year
Waiver Year: Year 3 SNF
49.33/day
42.58/day
1,657,043
37 half-days
22.53/day
51.31/unit
Agency, non- assisted living - Daily
36.00/day
Agency, non-assisted living - Hourly
2,008,908
Individual – Hourly
9.79/hr
7,958,996
1,012.11/mo
61 half-hr
7.39/half-hr
37.35/hr
74.94/visit
Respite: Home Health Aide
40.40/hr
20.48/hr
Respite: Home Care Agency
7.20/hr
Respite: Facility
7.21/hr
5.36/hr
21.66/hr
Home & Vehicle Mod.
524.31/unit
5.07/meal
PERS Install
33.93/install
4.26/hr
0.31/mile
6.54/trip
9 qtr hrs
8.06/qtr hr
Self Directed Personal Care service
Self directed community supports and employment
43,078,619
TOTAL ESTIMATED UNDUPLICATED PARTICIPANTS (from Table J-2-a)
FACTOR D (Divide total by number of participants)