Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018. c-1. 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. Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018. d. 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). i. 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 % Specify percentage: 300% of the SSI Federal Benefit Rate (FBR) The following dollar amount: $ If this amount changes, this item will be revised The following formula is used to determine the needs allowance: Specify formula: Other Specify: ii. 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:
b Sub-assurance: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver. i. Performance Measures For each performance measure the State will use to assess compliance with the statutory 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: No longer needed given new QM system. Data Source (Select one) (Several options are listed in the on-line application): If ‘Other’ is selected, specify: No longer needed 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 No longer needed Continuously and Ongoing Stratified: Describe Group: Other Specify: No longer needed Other Specify: No longer needed Add another Data Source for this performance measure 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
be provided by (check each that applies): Responsible Person Provider Specifications Provider Category(s) Individual. List types: Agency. List the types of agencies: Residential Support Agencies Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Residential Support Agencies 115 CMR 7.00 (Department of Developmental Services Standards for all Services and Supports) and 115 CMR 8.00 (Department of Developmental Services Certification, Licensing and Enforcement Regulations) or 104 CMR Chapter 28 (Department of Mental Health regulations governing Licensing and Operational Standards for Community Programs). Residential Support Agency Provider employees must have a High School diploma, GED or relevant equivalencies or competencies. Residential Support Agency Provider employees must possess appropriate qualifications as evidenced by interview(s), two personal or professional references and a Criminal Offender Records Inquiry (CORI), be age 18 years or older, be knowledgeable about what to do in an emergency; be knowledgeable about how to report abuse and neglect, have the ability to communicate effectively in the language and communication style of the participant, maintain confidentiality and privacy of the consumer, respect and accept different values, nationalities, races, religions, cultures and standards of living. Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Residential Support Agencies Department of Developmental Services (DDS) Office of Quality Enhancement, Survey and Certification staff. Every two years C-1/C-3: Service Specification Service Type: Other Service Service: Specialized Medical Equipment Service Specification Service Definition (Scope): Specialized Medical Equipment includes: (a) devices, controls, or appliances, specified in the plan of care, that enable participants to increase their ability to perform activities of daily living; (b) devices, controls, or appliances that enable the participant to perceive, control, or communicate with the environment in which they live; (c) items necessary for life support or to address physical conditions along with ancillary supplies and equipment necessary to the proper functioning of such items; (d) such other durable and non-durable medical equipment not available under the State plan that is necessary to address participant functional limitations; and, (e) necessary medical supplies not available under the State plan. In addition to the acquisition of the Specialized Medical Equipment itself this service may include:
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 Administrative Services Organization Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: Add another Data Source for this performance measure 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: b Sub-Assurance: The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements. i. Performance Measures For each performance measure the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator.
Data Source (Select one) (Several options are listed in the on-line application): Other If ‘Other’ is selected, specify: SC Supervisor Tool 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 95% Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: Add another Data Source for this performance measure 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: Add another Performance measure (button to prompt another performance measure) Performance Measure: % of service plans that reflect personal goals identified through the assessment process. (Number of service plans that address personal goals identified during the assessment process/ Number of service plans
reviewed) Data Source (Select one) (Several options are listed in the on-line application): Other If ‘Other’ is selected, specify: SC Supervisor Tool 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 95% Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: Add another Data Source for this performance measure 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: Add another Performance measure (button to prompt another performance measure) Performance Measure: % of service plans that have been developed in accordance with waiver requirements as indicated by the inclusion of all required components,
Other Specify: Annually No longer needed Continuously and Ongoing Other Specify: No longer needed Add another Performance measure (button to prompt another performance measure) c. Sub-assurance: Service plans are updated/revised at least annually or when warranted by changes in the waiver participant’s needs. i. Performance Measures For each performance measure the State will use to assess compliance with the statutory 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: % of service plans that are completed and/or updated annually. (Number of service plans completed and/or updated annually/ Number of service plans reviewed) Data Source (Select one) (Several options are listed in the on-line application): If ‘Other’ is selected, specify: SC Supervisor Tool 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 95% Continuously and Ongoing Stratified: Describe Group: Other
Add another Data Source for this performance measure 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: Add another Performance measure (button to prompt another performance measure) Performance Measure: % of participants receiving services subject to licensure and certification who know how to report abuse and/or neglect. (Number of participants receiving services subject to licensure and certification who know how to report abuse and neglect/ Number of individuals reviewed) Data Source (Select one) (Several options are listed in the on-line application): Provider Performance Monitoring 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 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample; Confidence Interval = Other Specify: Annually 95% Continuously and Ongoing Stratified: Describe Group: Other Specify:
Other Specify: Add another Data Source for this performance measure 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: Add another Performance measure (button to prompt another performance measure) Performance Measure: % of medication occurrences. (Number of medication occurrences report/ Number of medication doses administered) Data Source (Select one) (Several options are listed in the on-line application): Medication administration data reports, logs 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 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample; Confidence Interval = Other Specify: Annually Administrative Services Organization Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify:
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: Add another Performance measure (button to prompt another performance measure) Performance Measure: % of providers who conduct CORI’s of prospective employees and take appropriate action when necessary. (Number of providers that conduct CORI's of prospective employees and take required action/ Total number of providers reviewed) Data Source (Select one) (Several options are listed in the on-line application): Provider Performance Monitoring 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 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample; Confidence Interval = Other Specify: Annually Administrative Services Organization Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: Add another Data Source for this performance measure Data Aggregation and Analysis Responsible Party for Frequency of data
Specify: Continuously and Ongoing Other Specify: Add another Performance measure (button to prompt another performance measure) Performance Measure: % of individuals who have had an annual dental visit in the last 15 months. (Number of individuals with a documented dental visit in the past 15 months/ Number of individuals reviewed) Data Source (Select one) (Several options are listed in the on-line application): provider performance monitoring 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 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample; Confidence Interval = Other Specify: Annually 95% Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: Add another Data Source for this performance measure 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
b. Methods for Remediation/Fixing Individual Problems i. 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. DDS is responsible for ensuring that provider billing is in accordance with the services authorized in the service plan. The Administrative Service Organization (ASO) will ensure that services are billed in accordance with the established rate for the service provided. If any discrepancy is noted the ASO will report the error to MassHealth and/or DDS and/or service provider and the services will only be claimed upon reconciliation of the discrepancy. Claims that cannot be reconciled with payment vouchers or other service documentation will be reported to DDS and will be denied. ii. 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: c. 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 Financial Accountability that are currently non-operational. No Yes Please provide a detailed strategy for assuring Financial Accountability, the specific timeline for implementing identified strategies, and the parties responsible for its operation.
Supports Specialized Medical Equipment Item 384 5 $ 407.12 $ 781,670.40 Speech Therapy Visit 44 72 $ 78.52 $ 248,751.36 Transitional Assistance –RH Episode 40 2 $ 1,108.42 $ 88,673.60 Transportation One-Way Trip 378 300 $ 37.06 $ 4,202,604.00 GRAND TOTAL: $132,221,589.16 TOTAL ESTIMATED UNDUPLICATED PARTICIPANTS (from Table J-2-a) 676 FACTOR D (Divide grand total by number of participants) $195,594.07 AVERAGE LENGTH OF STAY ON THE WAIVER 344 Waiver Year: Year 4 (only appears if applicable based on Item 1-C) Waiver Service / Component Col. 1 Col. 2 Col. 3 Col. 4 Col. 5 Unit # Users Avg. Units Per User Avg. Cost/ Unit Total Cost Residential Habilitation Per Diem 621 347 $ 564.18 $ 121,573,455.66 Supported Employment 15 Minute 117 1,032 $ 10.23 $ 1,235,211.12 Assisted Living Services Per Diem 35 347 $ 116.90 $ 1,419,750.50 Community Based Day Supports 15 Minute 212 3,558 $ 5.77 $ 4,352,287.92 Day Services Per Diem 343 126 $ 115.08 $ 4,973,527.44 Occupational Therapy Visit 104 53 $ 79.64 $ 438,975.68 Physical Therapy Visit 140 56 $ 76.39 $ 598,897.60 Shared Living-24 Hour Supports Per Diem 49 347 $ 236.53 $ 4,021,719.59 Specialized Medical Equipment Item 401 5 $ 422.59 $ 847,292.95 Speech Therapy Visit 46 72 $ 81.50 $ 269,928.00 Transitional Assistance –RH Episode 30 2 $ 1,150.54 $ 69,032.40 Transportation One-Way Trip 394 303 $ 38.47 $ 4,592,625.54