conferred when participant direction opportunities are subject to a waiver of statewideness. 5. Assurances Refer to the Application for a complete description of the assurances. Analyst No response required. 6. Additional Requirements Refer to the Application for a complete description of waiver requirements. Analyst Notes 6-A: Service Plan No response required. 6-B: Inpatients No response required. 6-C: Room and Board No response required. 6-D: Access to Services No response required. 6-E: Free Choice of Provider No response required. 6-F: FFP Limitation No response required. 6-G: Fair Hearing No response required. 6-H: Quality Management No response required. 6-I: Public Input Does the state describe how it secures public input into the waiver development? Yes No 6-J: Notice to Tribal Governments No response required. 6-K: Limited English Proficiency Persons No response required. 7. Contact Person(s) Analyst Notes 7-A: State Medicaid Agency Representatives Does the indicate who CMS should communicate regarding the waiver? Yes No 7-B: Operating Agency Representative (Only complete if the state has indicated that the waiver will be administered by a State agency (as provided in Does the state indicate who CMS should communicate regarding the waiver? Yes No N/A Note: The first line of communication between CMS and a state regarding a waiver application is through State Medicaid agency.
Yes No Is the frequency of oversight specified? Yes No A-3: Use of Contracted Entities Analyst Notes When waiver operational and administrative activities are performed by contracted entities, does the waiver specify the types of entities that perform such activities and describe the types of activities that are performed by each type of entity? Yes No N/A A-4: Role of Local/Regional Non-State Entities Analyst Notes (Complete only when states use Local/Regional Entities to provide waiver services.) Do local/regional non-state entities perform waiver operational and administrative functions at the local or regional level? This includes Public Agencies (e.g., counties or other entities under control of elected officials) or Non-Governmental Entities (e.g., AAA, county developmental disabilities authorities). Yes No Does the state specify the waiver operational activities/functions that local/regional non-state entities perform? Yes No Does the state describe the nature of the non-state entities? Yes No A-5: Responsibility for Assessment of Performance of Contracted and/or Local/Regional Non-State Entities Analyst Notes (Complete only when the state uses contracted (Item A-3 is checked) and/or local/regional non-state entities (Item A-4 is checked)) Does the state agency specify the state agency or agencies responsible for assessing the performance of contracted and/or local/regional non-state entities conducting waiver operational and administrative functions? Yes No A-6: Assessment Methods and Frequency Analyst Notes (Complete only when the state uses contracted (Item A-3 is checked) and/or local/regional non-state entities (Item A-4 is checked)) Does the state describe: The methods that are used to assess the performance of contracted and/or non-state entities to ensure that they perform assigned waiver operational and administrative functions are in accordance with waiver requirements? Yes No
Persons with mental illnesses. For each subgroup, the age range of the persons served by the waiver? Yes No That the target groups align with the levels of care specified in Item 1-F of the Application (Module 1). Yes No B-1-b: Additional Criteria (See waiver instructions for full explanation of additional criteria.) Are the waiver target group or groups sufficiently well-defined to permit the determination that an individual meets the target group criteria? Yes No Note: For IP designation the waiver targets only individuals who live with their families, in their own private residence, or in a living arrangement where fewer than four persons unrelated to the proprietor reside. B-1-c: Transition of Individuals Affected by Maximum Age Limit When the waiver does not provide for the continuation of services to waiver participants beyond the age limit specified in the waiver, are there transition planning procedures that link affected participants to another waiver or other services and supports that provide continuity of services in the community to the extent feasible? Yes No B-2: Individual Cost Limit Analyst Notes B-2-a: Individual Cost Limit When the waiver imposes a cost limit that is lower than the cost of institutional services, is the limit based on sound analysis and rationale that within the amount of the limit, the health and welfare of the waiver target population will be assured post entrance to the waiver? Yes No When the limit is expressed as an absolute dollar limit, does the waiver describe how the limit will be adjusted during the period in which the waiver is in effect? Yes No When a waiver imposes an individual cost limit, it is applied uniformly and fairly to all potentially eligible individuals. Yes No B-2-b: Method of Implementation of the Individual Cost (Complete only when the state applies any cost limit) Do the procedures take into account the full range of supports that the person requires in the community and include notification of the opportunity to request a Fair Hearing if enrollment is denied? Yes No B-2-c: Participant Safeguards Does the waiver:
E-2-a: Participant - Employer Authority E-2-a-i. Participant Employer Status (Complete only when the waiver offers the Employer Authority opportunity as indicated in E-1-b.) Has the State specified the participant’s employer status under the waiver as: Participant/Co-Employer? Are the types of agencies that serve as co-employers specified as Agency with Choice FMS? Yes No Participant/Common Law Employer? Both? When co-employer option is available, the State has mechanisms in place to ensure that individuals maintain authority and control over employees, and that the agency with choice service delivery model truly reflects the key elements of self-direction. Yes No N/A E-2-a-ii. Participant Decision Making Authority (Complete only if Employer Authority is indicated in E-1-b.) In order for the waiver to be considered to offer Employer Authority to participants, the participant must have the authority to conduct the following functions at a minimum: Recruit workers? Yes No Hire and discharge staff (common law employer)? Yes No Refer for hire and discharge from providing services (co-employer)? Yes No Specify qualifications? Yes No Determine staff duties? Yes No Schedule staff? Yes No Supervise staff? Yes No Evaluate staff performance? Yes No Note: For IP designation the participant must have the authority to conduct the full range of employer functions that are listed and supports must be available for each function. E-2-b: Authority E-2-b.i Participant Decision Making Authority (Complete only if In order for the waiver to be considered to offer Budget Authority to participants, the participant must at a minimum have the authority to: Determine the amount paid for each service in accordance with the state's policies? Yes No Schedule when services are provided? Yes No Identify service providers and refer for enrollment? Yes No Review and approve provider invoices? Yes No
If the first choice is selected, does the State provide specific methods to detect unauthorized use of restraints and specify the state agency (or agencies) responsible for conducting this oversight? No Yes Note: In cases where the waiver serves a population (e.g., MR/DD or TBI, children with serious emotional disturbance) for whom the use of restraints and restrictive interventions is common and the state indicates that the Appendix does not apply, the reviewer is advised to confirm with the state that such interventions are prohibited. The state must complete Item G-2-c.ii. to describe how the state detects unauthorized use. G-2-a-i Safeguards Concerning the Use of Restraints (Complete only when the use of restraints and/or restrictive interventions is permitted during the course of the provision of waiver services regardless of setting.) For each type of restraint permitted, has the state identified safeguards that address: The use of alternative methods to avoid the use of restraints? Yes No Methods for detecting the unauthorized use of restraints? Yes No The protocols that must be followed when restraints are employed (including the circumstances when their use is permitted) and how their use is authorized? Yes No The practices that must be employed to ensure the health and safety of individuals? Yes No Required documentation concerning the use of restraints? Yes No Education and training requirements that personnel who are involved in the administration of restraints must meet? Yes No G-2-a-ii Oversight Responsibility Does the state’s response specify: The state agency (or agencies) responsible for overseeing the use of restraints and ensuring that the state’s safeguards are followed? Yes No When oversight is not performed by the Medicaid agency or the operating agency (if applicable), the process for the oversight agency to communicate information and findings to the Medicaid agency and/or operating agency? Yes No
I-2-c: Certifying Public Expenditures Does the use CPEs? Yes No N/A When CPEs are made, does the waiver specify: The state and/or local government agencies that certify the expenditures? Yes No The processes used to ensure that CPEs are based on total computable waiver costs? Yes No The processes to verify that the CPEs are eligible for federal financial participation? Yes No I-2-d: Billing Validation Process Do the billing validation methods address the three essential tests (below): The individual was eligible for Medicaid waiver payment on the date of service? Yes No The service was included in the participant’s approved service plan? Yes No; and The services were provided? Yes No I-2-e: Billing and Claims Record Maintenance Requirement No review required I-3: Payment Analyst Notes I-3-a: Methods of Payments -- MMIS Are payments for all waiver services made through an approved MMIS? Yes No If No, does the waiver specify: The processes that are used to make payment? Yes No How the processes ensure the maintenance of a proper trail? Yes No That providers may receive payment directly from the Medicaid agency? Yes No When payments for waiver services are made by a managed care entity or entities, does the waiver describe how the monthly capitated payments are made to the managed care entity or entities? Yes No N/A I-3-b: Direct Payment Does the Medicaid agency make payments directly to providers of waiver services? Yes No When a limited fiscal agent is employed, does the waiver specify: The entity or entities that as a limited fiscal agent? Yes No The payment functions performed by the limited fiscal agent? Yes No
Does the apportionment method used provide that only the participant’s additional rent and food costs associated with having a live-in caregiver are reimbursed? Yes No Are only the incurred by the participant reimbursed? Yes No Does the method of making payment for a live-in caregiver the payment through the provider but clearly provide for the reimbursement of the participant? Yes No I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing Analyst Notes I-7-a: State Requirement for Co-pays I-7-a –i: Co-pay Arrangement I-7-a -ii. Participants Subject to Co-Pay Charges for Waiver Services I-7-a-iii. Amount of Co-Pay Charges for Waiver Services I-7-a-iv. Cumulative Maximum Charges Does the state impose a co-payment or similar charge upon participants for waiver services? Yes No If Yes, Are the types of charges imposed on waiver participants specified? Yes No Do the groups subject to co-payment comply with the applicable provisions of 42 CFR §447.53? Notably, that children up to the age of 18 (or up to age 19, 20, or 21 at the state’s option) are excluded from co-payment. Yes No Does the state specify for each waiver services for which a co-payment is made, the amount and basis of the charge? The amount of the co-payment charge may not exceed the schedule of allowable charges contained in 42 CFR §447.54(a)(3) that establishes maximum charges based on the cost of a service. Yes No Does the state specify whether there is a cumulative maximum amount of co-payments that may be charged to a waiver participant? Yes No I-7-b: Other State Requirements for Cost Sharing Does the impose a premium, enrollment fee, or similar cost-sharing arrangement on waiver participants? Yes No If Yes, the state has specified: The type of cost sharing arrangement? Yes No The amount of the cost-sharing charge? Yes No How the amount of the charge is related to total gross family income in 42 CFR §447.52? Yes No The groups of participants who are subject to cost-sharing and the groups excluded – this must comply with 42 CFR §447.53 (no children)? Yes No
J-2-c-iii: Factor G Derivation J-2-c-iv: Factor G’ Derivation Is Factor D’ greater than or equal to Factor G’? Yes No If No, does the state provide an explanation for this? Yes No Is Factor D’ developed through sampling a comparable population? Yes No If Yes, has the state provided information on the process used and how the D’ value was derived? Yes No Is the for the Factor G estimate fully documented, evidence-based, and appropriately justified? Yes No Are any deviations from CMS-372(S) data adequately explained, justified, and documented? Yes No Is the basis for the Factor G’ estimate fully documented, evidence-based, and appropriately justified? The projected first year G’ value should not deviate substantially from previous year trends unless the state has altered its Medicaid program. Yes No Are any deviations from CMS-372(S) data adequately explained, justified, and documented? Yes No J-2-d: Estimate of Factor D J-2-d-i: Estimate of Factor D – Non-Concurrent Waiver J-2-d-ii: Estimate of Factor D – Concurrent §1915(b)/§1915(c) Waivers For Non-Concurrent Waivers: Is the unit of service identified for each service? Yes No Does the estimated number of units per user reflect the estimated ALOS rather than the potential maximum number of service units that a participant may utilize? Yes No For Concurrent Waivers, when there are services paid outside the capitation rate, has the state calculated: The total of all waiver costs? Yes No The subtotal for services paid within the capitation rate? Yes No The subtotal for services paid outside the rate? Yes No The average cost per unduplicated participant for all waiver services? Yes No The average costs for services paid within and outside the capitation rate? Yes No