Performance Measure: Number and percentage of timely notice of appeal rights provided to waiver applicants/participants who make one of the following claims: a) denied access to Medicaid Waiver Program, b) denied access to needed services while enrolled in the waiver, c) denied choice of provider if more than one qualified provider was available to render the service Data Source (Select one) (Several options are listed in the on-line application): If ‘Other’ is selected, specify: 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) X State Medicaid Agency Weekly 100% Review X Operating Agency Monthly X Less than 100% Review Sub-State Entity Quarterly X Representative Sample; Confidence Interval =5 Other Specify: Annually X Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: Data Source (Select one) (Several options are listed in the on-line application): If ‘Other’ is selected, specify: Responsible Party for data collection/generation (check each that Frequency of data collection/generation: (check each that applies) Sampling Approach (check each that applies)
B-3: Number of Individuals Served - Attachment #1 Waiver Phase-In/Phase Out Schedule Based on Waiver Proposed Effective Date: a. The waiver is being (select one): Phased-in Phased-out b. Phase-In/Phase-Out Time Schedule. Complete the following table: Beginning (base) number of Participants: Phase-In or Phase-Out Schedule Waiver Year: Month Base Number of Participants Change in Number of Participants Participant Limit
HCBS Taxonomy Category 1: Sub-Category 1: Category 2: Sub-Category 2: Category 3: Sub-Category 3: Category 4: Sub-Category 4: Service Definition (Scope): Financial Management Services is offered in support of the Self-Administered Services delivery option. Services rendered under this definition include those to facilitate the employment of respite services providers by the child’s parent including: a) Provider qualification verification; b) Employer-related activities including federal, state, and local tax withholding/payments, unemployment compensation fees, wage settlements, fiscal accounting and expenditure reports; c) Medicaid claims processing and reimbursement distribution, and d) Providing monthly accounting and expense reports to the consumer. Specify applicable (if any) limits on the amount, frequency, or duration of this service: Service is provided to those utilizing Self-Administered Services Service Delivery Method (check each that applies): Participant-directed as specified in Appendix E X Provider managed Specify whether the service may be provided by (check each that applies): Legally Responsible Person Relative Legal Guardian Provider Specifications Provider Category(s) (check one or both): Individual. List types: X Agency. List the types of agencies: Licensed Public Accounting Agency Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Licensed Public Accounting Agency Certified Public Accountant Sec 58-26A, UCA And R 156-26A, UAC Sec 58-26A, UCA And R 156-26A, UAC Certified by the BACBS as an authorized provider of services and supports. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA Comply with all applicable State and Local licensing, accrediting, and certification requirements.
State Medicaid Agency Weekly X 100% Review X Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample; Confidence Interval = Other Specify: Annually X Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: Data Source (Select one) (Several options are listed in the on-line application): If ‘Other’ is selected, specify: 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 X 100% Review X Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample; Confidence Interval = Other Specify: Annually X Continuously and Ongoing Stratified: Describe Group: 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 X Operating Agency Monthly Sub-State Entity Quarterly Other Specify: X Annually Continuously and
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 PCSPs that address all participants assessed needs including health needs, safety risks and personal goals by the provision of a sufficient amount of covered waiver services and other services including State Plan, generic and natural supports. Data Source (Select one) (Several options are listed in the on-line application): If ‘Other’ is selected, specify: 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) X State Medicaid Agency Weekly 100% Review X Operating Agency Monthly X Less than 100% Review Sub-State Entity Quarterly X Representative Sample; Confidence Interval =5 Other Specify: Annually X Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: Data Source (Select one) (Several options are listed in the on-line application): If ‘Other’ is selected, specify: 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) X State Medicaid Agency Weekly 100% Review X Operating Agency Monthly X Less than 100% Review Sub-State Entity Quarterly X Representative Sample; Confidence
Data Source (Select one) (Several options are listed in the on-line application): If ‘Other’ is selected, specify: 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) X State Medicaid Agency Weekly 100% Review X Operating Agency Monthly X Less than 100% Review Sub-State Entity Quarterly X Representative Sample; Confidence Interval =5 Other Specify: Annually X Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: Data Source (Select one) (Several options are listed in the on-line application): If ‘Other’ is selected, specify: 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) X State Medicaid Agency Weekly 100% Review X Operating Agency Monthly X Less than 100% Review Sub-State Entity Quarterly X Representative Sample; Confidence Interval =5 Other Specify: Annually X Continuously and Ongoing Stratified: Describe Group: 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 X State Medicaid Agency Weekly X Operating Agency Monthly Sub-State Entity Quarterly Other Specify: X Annually Continuously and Ongoing Other Specify: Performance Measure: SP c. 2. Number and percentage of PCSPs that were updated/revised when warranted by changes in the participant’s needs. Data Source (Select one) (Several options are listed in the on-line application): If ‘Other’ is selected, specify: 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) X State Medicaid Agency Weekly 100% Review X Operating Agency Monthly X Less than 100% Review Sub-State Entity Quarterly X Representative Sample; Confidence Interval =5 Other Specify: X Annually Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: Data Source (Select one) (Several options are listed in the on-line application): If ‘Other’ is selected, specify: Responsible Party for data collection/generation (check each that Frequency of data collection/generation: (check each that applies) Sampling Approach (check each that applies)
Continuously and Ongoing Other Specify: Performance Measure: SP e.2. Number and percentage of participants who are made aware of all services available on the Medicaid Autism Waiver as per the SIP. Data Source (Select one) (Several options are listed in the on-line application): If ‘Other’ is selected, specify: 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) X State Medicaid Agency Weekly 100% Review X Operating Agency Monthly X Less than 100% Review Sub-State Entity Quarterly X Representative Sample; Confidence Interval =5 Other Specify: Annually X Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: Data Source (Select one) (Several options are listed in the on-line application): If ‘Other’ is selected, specify: 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) X State Medicaid Agency Weekly 100% Review X Operating Agency Monthly X Less than 100% Review Sub-State Entity Quarterly X Representative Sample; Confidence Interval =5 Other Specify: Annually
analysis (check each that applies analysis: (check each that applies X State Medicaid Agency Weekly X Operating Agency Monthly Sub-State Entity Quarterly Other Specify: X Annually Continuously and Ongoing Other Specify: Performance Measure: Data Source (Select one) (Several options are listed in the on-line application): If ‘Other’ is selected, specify: 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) X State Medicaid Agency Weekly 100% Review X Operating Agency Monthly X Less than 100% Review Sub-State Entity Quarterly X Representative Sample; Confidence Interval =5 Other Specify: Annually X Continuously and Ongoing Stratified: Describe Group: 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 X State Medicaid Agency Weekly