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 Service 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: Add another Performance measure (button to prompt another performance measure) Performance Measure: % of providers licensed by DDS that continue to meet applicable licensure or certification standards. (Number of providers that continue to meet applicable licensure or certification standards/ Number of providers subject to licensure/certification) Data Source (Select one) (Several options are listed in the on-line application): Provider performance monitoring If ‘Other’ is selected, 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 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 that are not subject to DDS licensure and/or certification that have been trained and are current in all required trainings. (Number of providers (not subject to DDS licensure and/or certification) that have been trained/ 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 Service Organization Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify:
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
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): 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:
a Sub-assurance: The State provides evidence that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver and only for services rendered. (Performance measures in this sub-assurance include all Appendix I performance measures for waiver actions submitted before June 1, 2014.) a.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: Service . % of claims submitted to and paid by MMIS will be monitored and reported using remittance advices. (Approved and paid MMIS claims/ Total service claims submitted) Data Source (Select one) (Several options are listed in the on-line application): Financial records (including expenditures) 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: Other Specify: Other Specify: Add another Data Source for this performance measure Data Aggregation and Analysis Responsible Party for data aggregation and Frequency of data aggregation and
Sample; Confidence Interval = Other Specify: 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 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) ii. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible. The Administrative Service Organization reviews all claims prior to submission. The ASO will submit quarterly reports to DDS. Data are aggregated and analyzed annually to ensure services are billed in accordance with established waiver service payment rates. 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.
Supports waiver services. Expenditures are certified annually utilizing cost report data. from the Public Provider Reimbursement Unit at the University of Massachusetts Medical School (UMMS) Center for Health Care Financing review cost reports and allowable and disallowable costs (such as room and board). ayments to providers . These providers retain 100% of the payment. Certified Public Expenditures (CPE) of Local Government Agencies. Specify: (a) the local government agencies that incur certified public expenditures for waiver services; (b) how it is assured that the CPE is based on total computable costs for waiver services; and, (c) how the State verifies that the certified public expenditures are eligible for Federal financial participation in accordance with 42 CFR §433.51(b). (Indicate source of revenue for CPEs in Item I-4-b.) d. Billing Validation Process. Describe the process for validating provider billings to produce the claim for federal financial participation, including the mechanism(s) to assure that all claims for payment are made only: (a) when the individual was eligible for Medicaid waiver payment on the date of service; (b) when the service was included in the participant’s approved service plan; and, (c) the services were provided: The Massachusetts Medicaid Management Information System (MMIS) maintains date specific eligibility information on Medicaid waiver participants. Only service claims for participants whose MassHealth waiver eligibility is verified are submitted for payment processing. The participant’s case manager validates that the service was in fact provided and is included in the participant's approved Plan of Care. e. Billing and Claims Record Maintenance Requirement. Records documenting the audit trail of adjudicated claims (including supporting documentation) are maintained by the Medicaid agency, the operating agency (if applicable), and providers of waiver services for a minimum period of 3 years as required in 45 CFR § 92.42.
tables. Col. 2 fields will be populated ONLY when the Estimate of Factor D tables in J-2d have been completed. Level(s) of Care (specify): Hospital, Nursing Facility Col. 1 Col. 2 Col. 3 Col. 4 Col. 5 Col. 6 Col. 7 Col. 8 Year Factor D Factor D′ Total: D+D′ Factor G Factor G′ Total: G+G′ Difference (Column 7 less Column 4) 1 $177,526.02 $ 16,025.00 $ 193,551.02 $198,672.78 $13,296.21 $211,968.99 $ 18,417.97 2 $188,142.38 $ 16,969.28 $ 205,111.66 $210,379.61 $14,079.69 $224,459.30 $ 19,347.64 3 $195,594.07 $ 17,642.17 $ 213,236.24 $218,721.88 $14,638.00 $233,359.88 $ 20,123.64 4 $204,522.24 $ 18,443.09 $ 222,965.33 $228,651.50 $15,302.54 $243,954.04 $ 20,988.71 5 $212,651.18 $ 19,158.00 $ 231,809.18 $237,514.68 $15,895.71 $253,410.39 $ 21,601.21
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 GRAND TOTAL: $144,392,704.40 TOTAL ESTIMATED UNDUPLICATED PARTICIPANTS (from Table J-2-a) 706 FACTOR D (Divide grand total by number of participants) $204,522.24 AVERAGE LENGTH OF STAY ON THE WAIVER 347 Waiver Year: Year 5 (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 648 347 $ 585.62 $ 131,680,170.72 Supported Employment 15 Minute 122 1,033 $ 10.62 $ 1,338,396.12 Assisted Living Services Per Diem 37 347 $ 121.34 $ 1,557,884.26
Community Based Day Supports 15 Minute 221 3,561 $ 5.99 $ 4,714,016.19 Day Services Per Diem 357 127 $ 119.45 $ 5,415,743.55 Occupational Therapy Visit 108 53 $ 82.67 $ 473,203.08 Physical Therapy Visit 146 56 $ 79.29 $ 648,275.04 Shared Living-24 Hour Supports Per Diem 52 347 $ 245.52 $ 4,430,162.88 Specialized Medical Equipment Item 418 5 $ 438.65 $ 916,778.50 Speech Therapy Visit 48 72 $ 84.60 $ 292,377.60 Transitional Assistance –RH Episode 30 2 $ 1,194.26 $ 71,655.60 Transportation One-Way Trip 411 303 $ 39.93 $ 4,972,602.69 GRAND TOTAL: $156,511,266.23 TOTAL ESTIMATED UNDUPLICATED PARTICIPANTS (from Table J-2-a) 736 FACTOR D (Divide grand total by number of participants) $212,651.18 AVERAGE LENGTH OF STAY ON THE WAIVER 347