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 Contracted Entity Local Non-State Entity Participant waiver enrollment x x Waiver enrollment managed against approved limits x x Waiver expenditures managed against approved levels x x Level of care evaluation x x Review of Participant service plans x x Prior authorization of waiver services x x Utilization management x x Qualified provider enrollment x x Execution of Medicaid provider agreements x Establishment of a statewide rate methodology x x Rules, policies, procedures and information development governing the waiver program x x Quality assurance and quality improvement activities x x Quality Improvement: Administrative Authority of the Single State Medicaid Agency As a distinct component of the State’s quality improvement strategy, provide information in the following fields to detail the State’s methods for discovery and remediation. a. Methods for Discovery: Administrative Authority
X Other Specify: Every two years 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 X Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing X Other Specify: Every two years Performance Measure: Number and percentage of Level of Care is determinations documented in USTEPS. The numerator is the number of Level of Care determinations reviewed and which have been documented in USTEPS; the denominator is the total number of Level of Care determinations made by the OA which were reviewed. Data Source (Select one) (Several options are listed in the on-line application):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) 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 = 95% Confidence Level, 5% Margin of Error Other Specify: X Annually
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: Individual Medicaid Provider Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Individual Medicaid Provider Certified by DSPD as an Acquired Brain Injury Support Coordinator (ABISC). The ABISC certification process is an internal process offered through DSPD. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA. Qualified support coordinators shall possess at least a Bachelor's degree in nursing, behavioral science or a human services related field such as social work, sociology, special education, rehabilitation counseling, or psychology and demonstrate competency relating to the planning and delivery of health services to the Acquired Brain Injury population through successful completion of a core curriculum and testing program approved by the State Medicaid Agency, leading towards certification of an Acquired Brain Injury Support Coordinator (ABISC). The certification process is an internal process offered through DSPD. Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Individual Medicaid Provider Division of Services for People with Disabilities: ABI Support Coordinators are monitored and evaluated on an ongoing basis by: A) their DSPD Supervisors, Annually
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: Day Supports Provider Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Day Supports Provider Site based: R501-2, UAC R539-6, UAC R539-7, UAC (4 or more individuals) Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA. Enrolled as a Medicaid provider Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Day Supports Provider Division of Services for People with Disabilities Annually Homemaker 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):
Category 2: Sub-Category 2: Category 3: Sub-Category 3: Category 4: Sub-Category 4: Service Definition (Scope): Consumer Preparation Services ensure that waiver recipients are prepared to supervise and direct their services providers. Consumer Preparation Services includes: (a) instruction in methods of identifying need and effectively communicating those needs to service providers; (b) instruction in management of provider(s) including interviewing, selecting, scheduling, termination, time sheeting, evaluating performance, back up coverage; (c) instruction in addressing problems such as changing levels of personal needs, grievance procedures, emergency coverage, exploitation and abuse. Consumer Preparation Services do not include educational, vocational or prevocational components. Specify applicable (if any) limits on the amount, frequency, or duration of this service: Limitations: Limits on the amount, frequency and/or duration are specified on the individual’s plan of care and based on assessed need. 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: Agency-based Consumer Preparation Services Provider Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Agency-based Consumer Preparation Services Provider Current business license Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA. Enrolled as a Medicaid provider
(check one or both): 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 Certified by the LTCB as an authorized provider of services and supports. Under State contract with LTCB as an authorized provider of services and supports. • Comply with all applicable State and Local licensing, accrediting, and certification requirements. • Understand the laws, rules and conditions that accompany the use of State and local resources and Medicaid resources. • Utilize accounting systems that operate effectively on a large scale as well as track individual budgets. • Utilize a claims processing system acceptable to the Utah State Medicaid Agency. • Establish time lines for payments that meet individual needs within DOL standards. • Generate service management, and statistical information and reports as required by the Medicaid program. • Develop systems that are flexible in meeting the changing circumstances of the Medicaid program. • Provide needed training and technical assistance to clients, their representatives, and others. • Document required Medicaid provider qualifications and enrollment requirements and maintain results in provider/employee file. • Act on behalf of the person receiving supports and services for the purpose of payroll reporting. • Develop and implement an effective payroll system that addresses all related tax obligations. • Make related payments as approved in the person’s budget, authorized by the case management agency.
Behaviorist Current business license Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA Training and experience in the field of acquired brain injuries of at least one year’s length; completion of a training course in positive behavioral supports prescribed by DSPD and approved by the SMA and the successful completion of a learning assessment at the conclusion of the course. Enrolled as a Medicaid provider Agency-based Behavior Consultation Service I Current business license Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA Training and experience in the field of acquired brain injuries of at least one year’s length; completion of a training course in positive behavioral supports prescribed by DSPD and approved by the SMA and the successful completion of a learning assessment at the conclusion of the course. Enrolled as a Medicaid provider Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Behaviorist Division of Services for People with Disabilities Annually Agency-based Behavior Consultation Service I Division of Services for People with Disabilities Annually Behavior Consultation II HCBS Taxonomy Category 1: Sub-Category 1: Category 2: Sub-Category 2:
Extended Living Supports Provider R501-2 UAC, R539-6 UAC (4 or more individuals) Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA. Enrolled as Medicaid provider Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Extended Living Supports Provider Division of Services for People with Disabilities Annually Living Start-Up Costs 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): Living Start-Up Cost are for individuals transitioning from a more restrictive living arrangement to a less restrictive living arrangement, this service provides reimbursement for the purchase of essential household items needed to establish basic living arrangements that allow the individual to live safely in the community. Essential household items include a bed, a table, chairs, bathroom furnishings, pots, pans, storage containers, utensils, broom, vacuum, plates, dishes, bowls, cups, telephone, answering machine, alarm clocks, hangers, duplicate keys, locks, non-refundable set-up fees or deposits for utility or service access (e.g. telephone, electricity, heating). Specify applicable (if any) limits on the amount, frequency, or duration of this service: Limitations: Reimbursement for the cost of rent or food is not a covered expense under this service. Reimbursable items are limited to only those household items that are essential. Reimbursement for entertainment and diversional items such as televisions, stereos, DVD players, VCR’s, CD players, or gaming systems, etc. is prohibited. Reimbursement for the cost of refundable fees or deposits is not a covered expense under this service.
Category 3: Sub-Category 3: Category 4: Sub-Category 4: Service Definition (Scope): Personal Budget Assistance provides assistance with financial matters, fiscal training, supervision of financial resources, savings, retirement, earnings and funds monitoring, monthly check writing, bank reconciliation, budget management, tax and fiscal record keeping and filing, and fiscal interaction on behalf of the individual. Specify applicable (if any) limits on the amount, frequency, or duration of this service: 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: Agency-based - Personal Budget Assistance Provider Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Agency-based - Personal Budget Assistance Provider Current business license Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA. Enrolled as a Medicaid provider Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Agency-based - Personal Budget Assistance Provider Division of Services for People with Disabilities Annually
Service Animal 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): Service animal means any guide dog, signal dog, or other animal individually trained to do work or perform tasks for the benefit of an individual with a disability, including but not limited to, guiding individuals with impaired vision, alerting individuals with impaired hearing to intruders or sounds, providing minimal protection or rescue work, pulling a wheelchair, or fetching dropped items. A service animal is an adaptive intervention specially trained to do work or perform tasks which benefit an individual with a disability or an individual who is aged. This service animal is intended to increase autonomy, to decrease functional limitations, to access the home or public environment, to provide for safety, and to reduce the risk of institutionalization. This service may include: the purchase of a trained animal; training for the recipient and animal; animal upkeep (food, license, tax, supplies); emergency and preventative Veterinarian services. Specify applicable (if any) limits on the amount, frequency, or duration of this service: 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: Service Animal Suppliers Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Service Animal Suppliers Current business license. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA.
Provider Category(s) (check one or both): Automated Medication Dispensary Equipment and Supply Suppliers Medical equipment and supply suppliers Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Automated Medication Dispensary Equipment and Supply Suppliers Current business license FCC registration of equipment placed in individual’s home. Enrolled with DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Enrolled as a Medicaid provider. Medical equipment and supply suppliers Current business license Enrolled with DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Enrolled as a Medicaid provider Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Automated Medication Dispensary Equipment and Supply Suppliers Division of Services for People with Disabilities Annually Medical equipment and supply suppliers Division of Services for People with Disabilities Annually Speech-Language Services HCBS Taxonomy Category 1: Sub-Category 1: Category 2: Sub-Category 2: Category 3: Sub-Category 3:
Specify: Every two years 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 X State Medicaid Agency Weekly X Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing X Other Specify: Every two years Performance Measure: Number and percentage of waiver participant deaths for which the Department of Human Services’ Fatality Review Committee process was followed. The numerator is the total number of waiver participant deaths for which the Department of Human Services’ Fatality Review Committee process was followed; the denominator is the total number of waiver participant deaths. Data Source (Select one) (Several options are listed in the on-line application):Other If ‘Other’ is selected, specify: Participant records and Annual 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 X 100% Review X Operating Agency Monthly Less than 100% Review Sub-State Entity X Quarterly Representative Sample; Confidence Interval = Other Specify: Annually Continuously and Ongoing Stratified: Describe Group:
incidents that required the development/implementation of prevention strategies. Data Source (Select one) (Several options are listed in the on-line application):Other If ‘Other’ is selected, specify: Participant records, Participant Service plans, Participant interviews and Provider interviews 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 = 95% Confidence Level, 5% Margin of Error Other Specify: Annually Continuously and Ongoing Stratified: Describe Group: X Other Specify: Every two years 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 X State Medicaid Agency Weekly X Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing X Other Specify: Every two years
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: Annually Continuously and Ongoing X Other Specify: Every two years d. Sub-assurance: The State establishes overall health care standards and monitors those standards based on the responsibility of the service provider as stated in the approved waiver. 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 participants who received adequate assistance as needed to take their medications. The numerator is the total number of participants in the review sample which received adequate assistance as needed to take their medications; the denominator is the total number of participants reviewed. Data Source (Select one) (Several options are listed in the on-line application):Other If ‘Other’ is selected, specify: Participant interviews, Provider interviews, Incident reports and DSPD records 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
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 X State Medicaid Agency Weekly X Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing X Other Specify: Every two years Performance Measure: Number and percentage of providers in a representative sample receive and retain 100% of amounts claimed for Wavier services. The numerator is the total number of providers in the review sample which receive and retain 100% of amounts claimed for waiver services; the denominator is the total number of providers in the review sample. Data Source (Select one) (Several options are listed in the on-line application):Other If ‘Other’ is selected, specify: CAPS claims payment history report; MMIS claims payment history report; Provider Claims 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 = 95% Confidence Level, 5% Margin of Error
Other Specify: X Annually 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 X State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing X Other Specify: Every two years 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) State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample; Confidence Interval = Other Specify: Annually Continuously and Ongoing Stratified: Describe Group:
Professional Medication Monitoring - RN Per Episode 11 108 $7.58 $9,005.04 Professional Medication Monitoring - LPN Per Episode 5 87 $5.24 $2,279.40 Specialized Medical Equipment/Supplies/Assistive Technology - Purchase Per Episode 1 1 $663.20 $663.20 Specialized Medical Equipment/Supplies/Assistive Technology - Monthly Fee Monthly 3 7 $20.85 $437.85 Supported Living 15 Minute 94 2807 $4.97 $1,311,374.26 Non-Medical Transportation - Daily (Flat rate for all trips needed) Daily 47 177 $9.61 $79,945.59 Non-Medical Transportation - UTA Bus Pass Purchase Per Episode 14 11 $84.84 $13,065.36 Non-Medical Transportation - Mileage Per Mile 1 1630 $0.45 $733.50 Non-Medical Transportation - Per Trip (UTA) Per Episode 5 299 $3.79 $5,666.05 Service Animal Per Episode 1 10 $50.00 $500.00 GRAND TOTAL: $4,058,546.59 TOTAL ESTIMATED UNDUPLICATED PARTICIPANTS (from Table J-2-a) 130 FACTOR D (Divide grand total by number of participants) $31,219.59 AVERAGE LENGTH OF STAY ON THE WAIVER $337.00 Waiver Year: Year 2 Waiver Service / Component Col. 1 Col. 2 Col. 3 Col. 4 Col. 5 Unit # Users Avg. Units Per User Avg. Cost/ Unit Total Cost ABI Waiver Support Coordination Monthly 130 12 $210.05 $327,678.00 Day Supports - 15 minute 15 Minute 4 2153 $6.12 $52,705.44 Day Supports - daily (6 hr avg) Daily 40 178 $69.36 $493,843.20 Homemaker Services 15 Minute 1 647 $3.64 $2,355.08 Residential Habilitation - Facility Based Daily 25 288 $180.86 $1,302,192.00 Residential Habilitation - Facility Based - DCFS Daily 15 82 $173.19 $213,023.70 Residential Habilitation - Host Home/Professional Parent Daily 4 224 $137.61 $123,298.56