The address for the CMS web-based waiver application system is https://wms-mmdl.cms.gov/WMS/faces/portal.jsp. This will bring you to the website’s homepage.

On the left side of the screen are helpful links and downloads to guide you through various waiver application functions. The migration protocol download is a step-by-step guide on how to enter existing, approved waivers into the web-based system.

Click on Web-based 1915(c) Waiver Application. This will take you to the Login screen.

Important Note: When navigating within the waiver application, do not use your browser’s back and forward functions. Instead, use the navigational links within the application itself to browse through the application. Using the browser’s navigational tools will cause an error message and will not save your application properly.

At the Login screen enter your User Name and Password. Passwords are case sensitive. Select Log In.

To access a submitted Waiver Application select Detail, this will transfer you to the Waiver Detail Finder screen.

To access a submitted Waiver Application select Detail, this will transfer you to the Waiver Detail Finder screen.

Displays basic information for each application as well as operational buttons that allow you to access the application in order to perform a variety of different functions. The buttons displayed/enabled are determined by the status of the application and also the user’s role. Some of the basic functions are described below:

Basic Page One Functions

• Select Browse or Edit to enter the application. This will bring you to the Request Information page of the waiver.
• To access the application in Read only mode select Browse.
• The State Staff and the State Medicaid Director can select Print, Validate, Create Amendment, and Create Renewal.
• Only the State Medicaid Director Role has the authority to Submit, Unsubmit, or Withdraw an application.
• To withdraw a draft of an Application select the Withdraw button on this screen.
• State users can select Allow CMS View to allow CMS to view a draft application. This feature is available only to state users. CMS users should select the Browse Current button to view drafts that the states have made available.

Custom Navigational Functions

• Back or Continue - Selecting <--Back or Continue--> on the top or bottom right corners of the screen to move to the previous or next page.
• Left-side Navigation Bar – Using the navigation bar on the left side of each screen you can choose which appendix of the application you want to view. Within each appendix, you can select which section you want to view.
• Home - Will return you to the Home page.
• Finder - Will return you to the Finder Screen.
• Save - Will save the page you are currently completing. The system periodically saves pages automatically and also automatically saves data when you move from screen to screen.
• Validate - Will take you to the Validate Waiver Application screen. This feature will perform an edit check on all sections to confirm that all required fields have been correctly completed.
• Log Out - Will save your application and exit you from the system.
• Print - Will take you to the Printing Selection screen. This allows you to print your application by Appendix or in its entirety.

The Change Report has been revised so that it now displays fixed-width columns with column headers, the ID’s of users who made changes, change dates, and the latest group of changes (based on latest version submitted) are displayed first with the rest in descending chronological order.

Access the Change Report on Page One of the application. Select Change Report. The Change Report displays the latest change made to an item in the application. It is organized by Appendices with the latest group of changes (based on latest version submitted) displayed first and the remainder in descending chronological order. Column Headers include:

• Section/Appendix Subsection #
• Subsection Name
• Question #
• Question Name
• Change Type (MOD, ADD, DEL)
• Changed By (displays User Name)
• Change Date

Access the Change Log on Page One of the application. Select Change Log.

The Change Log accepts a range of dates. Enter the desired date range. Select Get Change Log. The Change Log shows all the changes made to the application within the selected date range. It is organized by the date in which changes were made to the application.

Note: If you select Get Change Log without entering a date range, the default display will include all change dates. The result can be very lengthy if many changes were made.

This feature allows CMS to view a draft application with the concurrence of the state. Only state users can enable this function. CMS users will be able to see the application in the finder and should select Browse Current on Page One of the application to view it and/or create a printable view. This is particularly useful when the state is making changes in the application at the request of CMS.

This feature allows the state to convert Version 3.4 applications to Version 3.5. First, confirm the current version of your application in the top right corner of the banner. If “application rev 34” is displaying, you can convert to version 3.5.

Select the Update Revision button on Page One. Select the Change button in the Revision Change screen. The application will redirect to Page One. Check the top right corner of the page that the application has converted to version 3.5 properly.

This component permits the state to provide a brief description of the waiver’s goals, objectives, organization and service delivery methods. It also contains the fundamental assurances and additional federal requirements that apply to the operation of a waiver. Some elements in this part of the 1995 standard waiver application format (e.g., target group specification) are now located in other parts of the application.

1. Request Information. This section provides Basic Information about the waiver.
   1. The State. The state field will automatically populate based on user ID.
   2. Program Title. This item is optional, but can be useful in locating the waiver in the Finder.
   3. Type of Request. From the choices provided, select the type of request.
   4. Type of Waiver. Select Regular or Model Waiver.
   5. Proposed Effective Date. Enter the proposed effective date of the waiver.
   6. Level(s) of Care. Select the level or levels of care that individuals must require in order to be considered for entrance to the waiver. As applicable, specify the specific type of institutional setting or subcategory of a level of care.
   7. Concurrent Operation with Other Programs. Indicate whether the waiver is or will be operated concurrently with a program that is operated under one of the other authorities listed.
   8. Dual Eligiblity for Medicaid and Medicare. Indicate whether this waiver provides services for individuals who are eligible for both Medicare and Medicaid.
2. Brief Waiver Description. Briefly describe the purpose of the waiver, including its goals, objectives, organizational structure and service delivery methods.
3. Components of the Waiver Request. This section summarizes the remaining components of the waiver application. Item E, Participant-Direction of Services is the only item that requires a selection. It asks whether the waiver provides participants the opportunity to direct some or all of their waiver services. If the waiver does, then Appendix E must be completed. If not, Appendix E is not completed.
4. Waivers Requested: §1915(c) of the Act permits the Secretary to grant waivers of three specific provisions of the Act.
   1. Comparability. §1902(a)(10)(B) of the Act provides that Medicaid services must be available to all categorically eligible individuals on a comparable basis.
   2. Income and Resources for the Medically Needy. Select whether the state requests a waiver of §1902(a)(10)(C)(i)(III) of the Act in order to use institutional income and resource rules for the medically needy
   3. Statewideness. A state may request a waiver of §1902(a)(1) of the Act so it can operate on a less than statewide basis.
5. Assurances. The items in this section do not require any actions. In order for CMS to approve the waiver, the state must ensure these Assurances are taking place in the operation of the waiver. The assurances are listed in this part of the waiver application, and by submitting the application the State indicates that it will abide by the assurances.
6. Additional Requirements. This section includes additional requirements that apply to the operation of the waiver over and above the assurances contained in 42 CFR §441.302. The only item in this section that requires a state response is 6-I Public Input.
7. Contact Persons:
   1. The Medicaid Agency representative with whom CMS should communicate regarding the Waiver Is. Provide the name and other contact information of the individual at the Medicaid agency with whom CMS should communicate regarding the waiver.
   2. If Applicable, the State operating agency representative with whom CMS should be communicating. The name and contact information of the individual at the operating agency with whom CMS should communicate regarding the waiver.
8. Authorizing Signature. The Signature and Submission Date Fields will be auto-completed when the State Medicaid Director submits the application.

Attachment #1 Transition Plan. If a new replacement waiver or a renewed waiver includes changes that will adversely affects individuals that are served by an approved waiver, then a transition plan is must be submitted with the application.

This appendix identifies the state agency that is responsible for the day-to-day waiver administration and operation, other contracted entities that perform waiver operational functions, and, if applicable, local/regional entities that also have waiver administrative responsibilities.

1. State Line of Authority for Waiver Operation. Select whether the waiver is operated by the Medicaid agency or by another state agency. When the waiver is operated by the Medicaid agency, specify whether it is operated by the Medical Assistance Unit or another division/unit within the Medicaid agency. When the waiver is operated by another state agency, specify the state agency and complete Item A-2.
2. Medicaid Agency Oversight of Operating Agency Performance. This item is only completed when the Medicaid agency does not operate the waiver.
3. Use of Contracted Entities. In certain circumstances the Medicaid Agency or the Operating Agency can contract with entities to perform operational activities and functions. Specify whether contracted entities perform waiver operational and administrative functions on behalf of the Medicaid agency and/or the operating agency (if applicable).
4. Role of Local/Regional Non-State Entities. Indicate whether local or regional non-state entities perform waiver operational and administrative functions and, if so, specify the type of entity. When such entities perform such functions, complete Items A-5 and A-6.
5. Responsibility for Assessment of Performance of Contracted and/or Local/Regional Non-State Entities. This item is only completed when contracted entities (as indicated in Item A-3) and/or local/regional non-state entities (as indicated in Item A-4) perform waiver operational and administrative functions.
6. Assessment Methods of Frequency. This item is only completed when contracted entities and/or local/regional non-state entities perform waiver operational and administrative functions, as indicated in Items A-3 and/or A-4.
7. Distribution of Waiver Operational and Administrative Functions. In the table, check the entity or entities that have responsibility for conducting each of the waiver operational and administrative functions that are listed.

1. Quality Improvement: Administrative Authority of the Single State Medicaid Agency

   Instructions: The QIS must describe how the state Medicaid Agency will determine that each waiver assurance (and its associated component elements) is met. The waiver assurance and component elements are listed above. For each component element, this description must include:

   • Activities or processes that are related to discovery and remediation, i.e., review, assessment or monitoring processes; who conducts the discovery or remediation activities and with what frequency. The information can be aggregated and analyzed to measure the overall system performance in meeting the waiver assurances. The types of information used to measure performance, should include relevant quality measures/indicators.
   • The entity or entities responsible for reviewing the results (data and information) of discovery and remediation activities to determine whether the performance of the system reflects compliance with the assurances; and,
   • The frequency at which system performance is measured.

   If the State does not have mechanisms currently in place to discover and remediate compliance with the respective waiver assurance, the State must provide (in item c) the timelines to design or implement methods for discovery and remediation related to the assurance that is currently non-operational. In this item, the state must provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

This Appendix specifies the target group(s) of Medicaid beneficiaries that the waiver serves, its scope, and the processes associated with entry into the waiver.

1. Specification of the Waiver Target Groups.
   1. Target Group(s). Select one of the three principal target groups. For the target group selected, select one or more of the subgroups listed.
   2. Additional Criteria. In the text field, indicate any additional criteria that further specify the target group(s) served by the waiver.
   3. Transition of Individuals by Maximum Age Limit. Describe the transition planning procedures followed to assist individuals that reach the maximum age limit on the waiver.
2. Individual Cost Limit
   1. Individual Cost Limit. Select one of the choices presented. As applicable, provide the additional information where requested.
   2. Method of Implementation of the Individual Cost Limit. If a cost limit is established then specify the procedures used to implement the limit in order to determine whether or not the individual’s health and welfare can be assured within the cost limit.
   3. Participant Safeguards. When an individual cost limit is specified, indicate the safeguards that are in effect when post-entrance, a waiver participant requires the provision of services in an amount that exceeds the cost limit in order to assure the participant’s health and welfare.
3. Number of Individuals Served.
   1. Unduplicated Number of Participants. Enter the maximum number of unduplicated participants who may be served during each waiver year that the waiver is in effect.
   2. Limitation on the Number of Participants Served at Any Point in Time. Select whether there is a limit on the number of individuals who may participate in the waiver at any point in time during a waiver year. If there is a limit, complete Table B-3-b by specifying the limit for each waiver year.
   3. Reserved Waiver Capacity. Specify whether waiver capacity is reserved for purposes specified by the state.
   4. Scheduled Phase-In or Phase-Out. When entrance to the waiver is subject to a phase-in schedule or the waiver is being phased-out, select the second choice and complete the table in Attachment #1 to Appendix B-3.
   5. Allocation of Waiver Capacity. Select whether waiver capacity is allocated/managed on a statewide basis or, instead, is allocated to local/regional non-state entities. In the latter case, specify: (a) the entities to which waiver capacity is allocated; (b) the methodology that is employed to allocate capacity; and, (c) policies for the reallocation of unused capacity among local/regional non-state entities.
   6. Selection of Entrants to the Waiver. In the text field, specify the policies that apply to the selection of individuals for entrance to the waiver.
4. Eligibility Groups Served in Waiver
   1. State Classification. A state may be a §1634 State, SSI-Criteria State, or a §209(b) State. These are mutually exclusive categories and the answer will determine which post-eligibility treatment of income rules apply in Appendix B-5. Both §1634 States and SSI States are considered “SSI States” in Appendix B-5.
   2. Medicaid Eligibility Groups Served in the Waiver. Specify each Medicaid eligibility group that is included in the waiver. Where indicated, furnish the additional information about a group.
5. Post- Eligibility of Income
   1. Use of Spousal Impoverishment Rules. Select whether spousal impoverishment rules are used to determine eligibility. If such rules are employed, also select whether the state elects to apply spousal post-eligibility rules.
   2. Regular Post-Eligibility Treatment of Income: SSI State. The state uses the post-eligibility rules at 42 CFR 435.726 for individuals who do not have a spouse or have a spouse who is not a community spouse as specified in §1924 of the Act.
   3. Regular Post-Eligibility Treatment of Income: 209(B) State. The state uses more restrictive eligibility requirements than SSI and uses the post-eligibility rules at 42 CFR 435.735 for individuals who do not have a spouse or have a spouse who is not a community spouse as specified in §1924 of the Act.
   4. Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules. This item must be completed whenever a state uses spousal impoverishment rules to determine eligibility and elects to apply spousal post-eligibility rules.
6. Evaluation/Reevaluation of Level of Care.
   1. Reasonable Indication of Need for Services. Specify: (a) the minimum number of services (at least one) that an individual must require in order to be determined to need waiver services and (b) the minimum frequency services must be needed - at least monthly or require monthly monitoring when services are furnished on less than a monthly basis.
   2. Responsibility for Performing Evaluations and Reevaluations. In this item specify the entity that performs the evaluations and reevaluations of level of care.
   3. Qualifications of Individuals Performing Initial Evaluation. In this item specify the qualifications of the professionals performing the evaluations and reevaluations. The credentials should be appropriate to the target population specified in the waiver application.
   4. Level of Care Criteria. In this item specify the criteria that are used to evaluate/re-evaluate level of care. The description should identify the factors that are assessed in evaluating level of care and the scoring system (if applicable) that is employed to determine level of care.
   5. Level of Care Instruments. Select whether the instrument/tool that is used to evaluate level of care for the waiver differs from the instrument/tool used to evaluate institutional level of care. If the tools are different, furnish the information requested.
   6. Process for Level of Care Evaluation/Reevaluation. Describe the process for evaluating waiver applicants for their need for the level of care under the waiver. If the reevaluation process differs from the evaluation process, describe the differences.
   7. Reevaluation Schedule. Specify the minimum frequency for the performance of level of care re-evaluations. Level of care must be re-evaluated at least annually.
   8. Qualifications of Individuals Who Perform Reevaluations. If the qualifications of the people who perform re-evaluations are different from the people who perform evaluations, specify the qualifications of individuals who perform re-evaluations in the text field.
   9. Procedures to Ensure Timely Reevaluations. In the text field, specify the procedures that are used to ensure timely re-evaluations of level of care.
   10. Maintenance of Evaluation/Reevaluation Records. In the text field, specify the location(s) where records of evaluations and reevaluations of level of care are maintained.

1. Quality Improvement: Level of Care

   Level of Care (LOC) Determination

   An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future. The LOC of enrolled participants are reevaluated at least annually or as specified in the approved waiver. The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant LOC.

   Instructions: The QIS must describe how the state Medicaid Agency will determine that each waiver assurance (and its associated component elements) is met. The waiver assurance and component elements are listed above. For each component element, this description must include:

   • Activities or processes that are related to discovery and remediation, i.e., review, assessment or monitoring processes; who conducts the discovery or remediation activities and with what frequency. The information can be aggregated and analyzed to measure the overall system performance in meeting the waiver assurances. The types of information used to measure performance, should include relevant quality measures/indicators.
   • The entity or entities responsible for reviewing the results (data and information) of discovery and remediation activities to determine whether the performance of the system reflects compliance with the assurances; and,
   • The frequency at which system performance is measured.

   If the State does not have mechanisms currently in place to discover and remediate compliance with the respective waiver assurance, the State must provide (in item c) the timelines to design or implement methods for discovery and remediation related to the assurance that is currently non-operational. In this item, the state must provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

7. Freedom of Choice
   1. Procedures. Describe the procedures that are followed to inform the individ-ual (or the person’s legal representative) of the feasible alternatives under the waiver and to document the individual’s choice of home and community-based services or institutional services.
   2. Maintenance of Forms. Specify the locations where copies of the forms that document that the participant has been informed of feasible alternatives and has exercised choice in the selection of waiver or institutional services are maintained.
8. Access to Services by Limited English Proficiency Persons

   Recipients of federal assistance (including Medicaid) are required to provide oral and written assistance to Limited English Proficient (LEP) persons to aid their access and use services. In this field, describe the accommodations made for LEP persons seeking waiver services.

Appendix C specifies the services that are provided in the waiver. Section C-1 and C-3 are combined in the on-line waiver application.

1. Summary of Services Covered
   1. Waiver Services Summary. This section contains a table that displays a summary list of all services covered in the waiver. Each time a service is added you will have the opportunity to complete the service specification template. A service specification needs to be completed for each waiver service added.
   2. Alternate Provision of Case Management Services to Waiver Participants. If case management is not covered as a waiver service then select the payment authority under which case management functions are conducted and specify the entities conducting those services in item C-1-c.
   3. Delivery of Case Management Services. In the text field, specify the entity or entities that conduct case management functions on behalf of waiver participants.
2. General Service Specifications
   1. Criminal History and/or Background Investigations. When individuals who provide waiver services must undergo a criminal history/background investigation, select the “Yes” response and provide the information required in the text field. If the state does not require that such investigations be conducted for any type of position that furnishes waiver services, select the “No” response.
   2. Abuse Registry Screening. If abuse registry screening is required, select the “Yes” response and provide the information required in the text field. If abuse registry screening is not conducted, select the “No” response.
   3. Provision of Personal Care or Similar Services by Legally Responsible Individuals. Indicate whether waiver services are furnished in facilities that are subject to §1616(e) of the Act.
   4. Other State Policies Concerning Payment for Waiver Services Furnished by Relatives/Legal Guardians. Select whether the waiver provides for extraordinary care payments to legally responsible individuals for the provision of personal care or similar services. Provide requested information in the text field.
   5. Other State Policies Concerning Payment for Waiver Services Furnished by Relatives/Legal Guardians. Select whether the state makes payments to relatives or legal guardians for any waiver service. If the state makes payments to relatives and/or legal guardians for waiver services, select one of the next three choices and provide the additional information under the choice that has been selected.
   6. Open Enrollment of Providers. In the text field, specify the processes that are employed to assure that all willing and qualified providers have the opportunity to enroll as waiver service providers.

1. Quality Improvement: Qualified Providers

   Qualified Providers

   The state verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other standards prior to their furnishing waiver services.

   The state monitors non-licensed/non-certified providers to assure adherence to waiver requirements.

   The state implements its policies and procedures for verifying that provider training is conducted in accordance with state requirements and the approved waiver.

   Instructions: The QIS must describe how the state Medicaid Agency will determine that each waiver assurance (and its associated component elements) is met. The waiver assurance and component elements are listed above. For each component element, this description must include:

   • Activities or processes that are related to discovery and remediation, i.e., review, assessment or monitoring processes; who conducts the discovery or remediation activities and with what frequency. The information can be aggregated and analyzed to measure the overall system performance in meeting the waiver assurances. The types of information used to measure performance, should include relevant quality measures/indicators.
   • The entity or entities responsible for reviewing the results (data and information) of discovery and remediation activities to determine whether the performance of the system reflects compliance with the assurances; and,
   • The frequency at which system performance is measured.

   If the State does not have mechanisms currently in place to discover and remediate compliance with the respective waiver assurance, the State must provide (in item c) the timelines to design or implement methods for discovery and remediation related to the assurance that is currently non-operational. In this item, the state must provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

3. Waiver Services Specification: Section C-3 ‘Service Specifications’ is incorporated into Section C-1 “Waiver Services”.
4. Limits
   1. Additional Limits on Amount of Waiver Services. This item must be completed whenever a state imposes a dollar limit on the amount of waiver services that may be authorized in a service plan over and above any limits on amount, duration and frequency that apply to individual waiver services.

This Appendix addresses Service plan development in Appendix D-1 and Service Plan implementation and monitoring in Appendix D-2. In the text field provided, enter the title of the Service Plan.

1. Service Plan Development
   1. Responsibility for Service Plan Development. Select who is responsible for the development of the Service Plan and then specify the qualifications these individuals must have.
   2. Service Plan Development Safeguards. Indicate whether the entities/or individuals responsible for the development of the service plan are permitted to provide other direct services to the waiver participant. If yes, then describe the safeguards that the state has established.
   3. Supporting the Participant in Service Plan Development. Specify: (a) the supports and information that are made available to the participant (and/or family or legal representative, as appropriate) to direct and be actively engaged in the service plan development process and (b) the participant's authority to determine who is included in the process.
   4. Service Plan Development Process. This item requires providing a comprehensive description of the service plan development process. It should include detailed descriptions of the sequence of activities, the integration of assessment information into service planning, and the distribution of roles and responsibilities.
   5. Risk Assessment and Mitigation. Specify how potential risks to the participant are assessed during the service plan development process and how strategies to mitigate risk are incorporated into the service plan, subject to participant needs and preferences. In addition, describe how the service plan development process addresses backup plans and the arrangements that are used for backup.
   6. Informed Choices of Providers. Waiver participants should be given ready access to information about qualified waiver providers that provide waiver services, so they can exercise their right to freely choose from any willing and qualified provider. Describe how participants are assisted in obtaining information about and selecting from among qualified providers of the waiver services in the service plan.
   7. Process for Making Service Plan Subject to the Approval of the Medicaid Agency. describe the process by which the service plan is made subject to the approval of the Medicaid agency
   8. Service Plan Review and Update. The service plan is subject to at least annual periodic review and update to assess the appropriateness and adequacy of the services as participant needs change. Indicate the minimum schedule for the review and update of the service plan.
   9. Maintenance of Service Plan Forms. Specify the location or locations where the service plans are maintained.
2. Service Plan Implementation and Monitoring
   1. Service Plan Implementation and Monitoring. Specify the service plan implementation and monitoring process in detail; include all items requested.
   2. Monitoring Safeguards. Indicate whether entities and/or individuals that are responsible for monitoring service plan implementation and participant health and welfare are permitted to provide other direct (non-case management) services to the waiver participant. If such entities and/or individuals are permitted to furnish other direct waiver services, describe the safeguards that have been established to ensure that monitoring is conducted in the best interests of the participant.

1. Quality Improvement: Service Plan

   Service Plan

   Service plans address all participants’ assessed needs (including health and safety risk factors) and personal goals, either by waiver services or through other means.

   The state monitors service plan development in accordance with its policies and procedures.

   Service plans are updated/revised at least annually or when warranted by changes in the waiver participant’s needs.

   Services are delivered in accordance with the service plan, including in the type, scope, amount, duration, and frequency specified in the service plan.

   Participants are afforded choice:

   • Between waiver services and institutional care; and
   • Between/among waiver services and providers.

   Instructions: The QIS must describe how the state Medicaid Agency will determine that each waiver assurance (and its associated component elements) is met. The waiver assurance and component elements are listed above. For each component element, this description must include:

   • Activities or processes that are related to discovery and remediation, i.e., review, assessment or monitoring processes; who conducts the discovery or remediation activities and with what frequency. The information can be aggregated and analyzed to measure the overall system performance in meeting the waiver assurances. The types of information used to measure performance, should include relevant quality measures/indicators.
   • The entity or entities responsible for reviewing the results (data and information) of discovery and remediation activities to determine whether the performance of the system reflects compliance with the assurances; and,
   • The frequency at which system performance is measured.

   If the State does not have mechanisms currently in place to discover and remediate compliance with the respective waiver assurance, the State must provide (in item c) the timelines to design or implement methods for discovery and remediation related to the assurance that is currently non-operational. In this item, the state must provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

Applicability: If the selection in Main 3-e was “Yes”, then this item will automatically be selected and this appendix must be completed.

Independence Plus: Indicate whether Independence Plus designation is requested.

1. Overview
   1. Description of Participant Direction. Provide an overview description of the participant direction opportunities that are afforded in the waiver. This overview is intended to provide CMS with a broad understanding of the waiver’s participant direction opportunities.
   2. Participant Direction Opportunities. Select whether the waiver provides for the Employer Authority, the Budget Authority or both opportunities for participant direction in combination. When the Employer Authority is selected, Item E-2-a must be completed in Appendix E-2. When the Budget Authority is selected, Item E-2-b must be completed in Appendix E-2. When the “Both Authorities” selection is made, both Items E-2-a and E-2-b must be completed in Appendix E-2.
   3. Availability of Participant Direction by Type of Living Arrangement. The waiver may limit participant direction by type of living arrangement. Check each choice that applies, and if applicable, specify living arrangements.
   4. Election of Participant Direction. Select one choice. If the third item is selected, specify the additional criteria that are applied in determining whether participants may direct some or all of their waiver services. These additional criteria should not include participant living arrangements.
   5. Information Furnished to Participant. Specify: (a) the information about participant direction opportunities; (b) the entity or entities responsible for furnishing this information; and, (c) how and when this information is provided on a timely basis.
   6. Participant Direction by a Representative. Specify the State's policy concerning the direction of waiver services by a representative. Select whether waiver services may be directed by a representative on behalf of the waiver participant and, if so, the type or types of representatives who may direct services. When a representative who is not a legal guardian may direct services, provide information about the policies that apply to the role of such representatives.
   7. Participant-Directed Services. Specify the participant direction opportunity (or opportunities) available for each waiver service that is specified as participant-directed in Appendix C-1/C-3. For each listed service, specify whether the Employer Authority, Budget Authority or both authorities apply to the service.
   8. Financial Management Services. Except in certain circumstances, financial management services are mandatory and integral to participant direction. A governmental entity and/or another third-party entity must perform necessary financial transactions on behalf of the waiver participant. If such services are provided, indicate whether they are provided by governmental or private entities or both.
   9. Provision of Financial Management Services. If Financial Management Services are provided as a Medicaid Administrative Activity then information about the nature and scope of the services must be provided in detail in this section of the application.
   10. Information and Assistance in Support of Participant Direction. Select the payment authority or authorities under which information and assistance in support of participant direction are furnished. Where required, provide the additional information that is requested.
   11. Independent Advocacy. Select whether or not Independence Advocacy is available. If such advocacy is available, describe the nature of such advocacy and how participants may access this support.
   12. Voluntary Termination of Participant Direction. Describe how the State accommodates a participant who voluntarily terminates participant direction in order to receive services through an alternate service delivery method, including how the State assures continuity of services and participant health and welfare during the transition from participant direction.
   13. Involuntary Termination of Participant Direction. Specify the circumstances when the State will involuntarily terminate the use of participant direction and require the participant to receive provide-managed services instead, including how continuity of services and participant health and welfare is assured during the transition.
   14. Goals for Participant Direction. In the table, provide the State's goals for each year that the waiver is in effect for the unduplicated number of waiver participants who are expected to elect each applicable participant direction opportunity.
2. Opportunities for Participant Direction.
   1. This item must be completed whenever the waiver offers the Employer Authority participant direction opportunity, as indicated in Appendix E-1, Item E-1-b.
   2. Indicate how the participant exercises control over a participant-directed budget by checking the decision-making authorities that the participant may exercise under the Budget Authority in the list displayed.

Appendix F addresses how participants can request a Fair Hearing; whether there is a dispute resolution process available to appeal decisions that adversely affect the participant’s services; and if there is a system available for participants to register complaints about their services.

1. Opportunity to Request a Fair Hearing. Describe how the individual (or his/her legal representative) is informed of the opportunity to request a fair hearing under 42 CFR Part 431, Subpart E. Specify the notice(s) that are used to offer individuals the opportunity to request a Fair Hearing. State laws, regulations, policies and notices referenced in the description are available to CMS upon request through the operating or Medicaid agency.
2. Additional Dispute Resolution Process.
   1. Availability of Additional Dispute Resolution Process. Indicate whether the State operates another dispute resolution process that offers participants the opportunity to appeal decisions that adversely affect their services while preserving their right to a Fair Hearing.
   2. Description of Additional Dispute Resolution Process. Describe the additional dispute resolution process, including: (a) the State agency that operates the process; (b) the nature of the process (i.e., procedures and timeframes), including the types of disputes addressed through the process; and, (c) how the right to a Medicaid Fair Hearing is preserved when a participant elects to make use of the process.
3. State Grievance/Complaint System
   1. Operation of Grievance/Complaint System. Select whether there is a grievance/complaint system that affords participants the opportunity to register grievances or complaints concerning the provision of services under this waiver. When there is such a system, complete the remaining two items. If there is not a system, do not complete the remainder of Appendix F-3.
   2. Operational Responsibility. Identify the state agency that is responsible for the operation of the grievance/complaint system.
   3. Description of System. Describe the grievance/complaint system and include all requested items. Also, specify how the system is structured to preserve the participant’s opportunity to request a Fair Hearing.

Appendix G addresses safeguards that assure the health and welfare of the participant. These safeguards include: responding to critical events or incidents, restraints and restrictive interventions, and medication management and administration.

1. G-1: Response to Critical Events or Incidents
   1. State Critical Event or Incident Reporting Requirements. This item focuses on critical events or incidents that the state views as serious enough to necessitate review and follow-up by an appropriate authority.
   2. Participant Training and Education. Describe how training and/or information is provided to participants (and/or families or legal representatives, as appropriate) concerning protections from abuse, neglect, and exploitation, including how participants (and/or families or legal representatives, as appropriate) can notify appropriate authorities or entities when the participant may have experienced abuse, neglect or exploitation.
   3. Responsibility for Review of and Response to Critical Events or Incidents. Specify the entity (or entities) that receive reports of critical events or incidents specified in item G-1-a, the methods that are employed to evaluate such reports, and the processes and time-frames for responding to critical events or incidents, including conducting investigations.
   4. Responsibility for Oversight of Critical Incidents and Events. Identify the State agency (or agencies) responsible for overseeing the reporting of and response to critical incidents or events that affect waiver participants, how this oversight is conducted, and how frequently.
2. G-2: Safeguards Concerning Restraints and Restrictive Interventions
   1. Use of Restraints or Seclusion. Restraints or Seclusion include personal restraints, drugs, and mechanical restraints and seclusion includes involuntary isolation of a person because of their behavior. A state agency needs to conduct oversight so that the health and welfare of the participant is assured with the use of restraints.
      • The State does not permit or prohibits the use of restraints or seclusion. Specify the State agency (or agencies) responsible for detecting the unauthorized use of restraints or seclusion and how this oversight is conducted and its frequency.
      • The use of restraints or seclusion is permitted during the course of the delivery of waiver services. Complete Items G-2-a-i and G-2-a-ii.
   2. Use of restrictive interventions. For the purposes of this item, restraints include personal restraints (e.g., holds), drugs used as restraints, and mechanical restraints. Seclusion means involuntarily isolating an individual as a means of controlling the person’s behavior.
      • The state does not permit or prohibits the use of restrictive interventions. Specify the State agency (or agencies) responsible for detecting the unauthorized use of restrictive interventions and how this oversight is conducted and its frequency.
      • The use of restrictive interventions is permitted during the course of the delivery of waiver services. Complete Items G-2-b-i and G-2-b-ii.
3. Medication Management and Administration.
   1. Applicability. If waiver services are furnished by a provider around the clock in a licensed or unlicensed living arrangement then this appendix must be completed. Select whether this Appendix applies to the waiver. If it applies, then complete the remainder of the Appendix. If not, do not complete the rest of the Appendix.
   2. Medication Management and Follow-Up. Medication management is the review of a participant’s full medicine to ensure that it’s appropriate.
   3. Medication Administration by Waiver Providers. This item concerns the administration of medications by waiver providers to waiver participants who are not able to self-administer their medications or the oversight by waiver providers of participant self-administration of medications.

1. Quality Improvement: Health and Welfare

   Health and Welfare

   The state, on an on-going basis, identifies, addresses, and seeks to prevent the occurrence of abuse, neglect and exploitation.

   Instructions: The QIS must describe how the state Medicaid Agency will determine that each waiver assurance (and its associated component elements) is met. The waiver assurance and component elements are listed above. For each component element, this description must include:

   • Activities or processes that are related to discovery and remediation, i.e., review, assessment or monitoring processes; who conducts the discovery or remediation activities and with what frequency. The information can be aggregated and analyzed to measure the overall system performance in meeting the waiver assurances. The types of information used to measure performance, should include relevant quality measures/indicators.
   • The entity or entities responsible for reviewing the results (data and information) of discovery and remediation activities to determine whether the performance of the system reflects compliance with the assurances; and,
   • The frequency at which system performance is measured.

   If the State does not have mechanisms currently in place to discover and remediate compliance with the respective waiver assurance, the State must provide (in item c) the timelines to design or implement methods for discovery and remediation related to the assurance that is currently non-operational. In this item, the state must provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

Here, a state describes the mechanisms it will use to engage in systems improvement activities based upon the information it gathers from the discovery and remediation strategies described throughout the application.

Quality Improvement Strategy in Waiver Application 3.5

The initial QIS is submitted as part of the waiver application. When the waiver is renewed, an updated QIS is submitted as part of the waiver application. Modifications or updates to the QIS are submitted to CMS as part of the State’s Annual Report on Home and Community-Based Services Waivers (HCFA 372(S) form), required under the provisions of 42 CFR §441.302(h).

The State has been asked to provide components of a Quality Improvement Strategy (QIS) in the Appendices of the application as follows:

• The measures and processes the state will use to determine that each waiver assurance is met during the period that the waiver is in effect (discovery);
• The measures and processes employed to correct identified problems (remediation);
• The roles and responsibilities of the parties involved in measuring performance and making improvements;
• The processes employed to aggregate and analyze trends in the identification and remediation of problems,
• The processes employed to establish priorities, develop strategies for, and assess implementation of system improvements (system improvement);
• The process and timelines for compiling the information and communicating to waiver participants, families, service providers, other interested parties, and the public; and,
• The frequency and processes used to evaluate and revise the QIS.

Additionally, Appendix H asks the state to describe:

• How information about performance is used to identify and prioritize areas for system improvement;
• How quality improvement information is compiled and communicated; and,

The process that the state will follow to assess the effectiveness of both the system improvement and the QIS and revise it as necessary and appropriate.

Instructions

Planned Quality Improvements. A state may not have a fully developed QIS when the waiver application is submitted. For example, a state may not have a system to compile information about the occurrence of and response to critical incidents but may plan to design and implement such a system during the period the waiver is in effect. Or a state may plan to create a Quality Improvement Council to identify and prioritize quality improvement activities but does not expect the Council to be established prior to the effective date of the waiver renewal. When elements of the QIS are not in place in a submitted application but will be developed and implemented during the period the waiver is in effect, the QIS should include a detailed work plan with specific steps and timelines for addressing the gap(s). The work plan should describe at minimum the specific tasks to be undertaken, major milestones associated with completing each task, estimated timeline for completion, and the entity (or entities) responsible for completing the tasks.

Multiple Waivers. It may be more efficient and effective for a QIS to span multiple HCBS waivers and other related long-term care services, especially when a state operates more than one waiver that serves the same or similar waiver target groups or multiple waivers employ similar quality improvement methods. While the QIS may span multiple waivers and/or other Medicaid long-term services, it must be designed to ensure it encompasses all requirements and assurances specific to each waiver. If the QIS applies to more than one waiver, the State must be sure to stratify information for each waiver separately. Also include: (a) the control numbers for the other waivers and (b) the other Medicaid long-term services to which the QIS applies.

The Quality Improvement Strategy must describe roles and responsibilities of the parties involved in discovery, remediation, and improvement activities. In other appendices the state has described the roles and responsibilities of parties involved in discovery and remediation. In Appendix H, the description should include the roles and responsibilities of the Medicaid agency, operating agency and non-state entities (as applicable), other state agencies, participants, families and advocates, providers, and other contractors (if appropriate) in effectuating the processes in the quality improvement strategy such as collecting and analyzing individual and system-level information, determining whether the waiver requirements and assurances are met, implementing remediation, and planning system improvement activities.

The focus of Appendix H is on identifying who is involved in appraising the state’s performance in meeting the waiver assurances based on the results of discovery processes. The parties involved in performance appraisal may vary by assurance, depending on the nature of the assurance. The state may organize the involvement of individuals and entities in any number of ways including, but not limited to, establishing a quality improvement unit, forming quality improvement councils, and establishing standing committees. It is not necessary that the Medicaid agency directly conducts every aspect of the quality improvement strategy. However, since the QIS revolves around meeting the waiver assurances, it is necessary that the Medicaid agency be the source of the delegation of activities in the QIS, and the recipient of the monitoring, remediation and system improvement reports that pertain to meeting the assurances. The Medicaid agency must also perform its own monitoring of all delegated activities.

QIS Processes to Establish Priorities, Develop, and Assess System Improvements

Instructions

The QIS must describe the processes employed to review findings from its discovery and remediation activities, to establish priorities for system improvement, and to evaluate the effectiveness of the improvements.

Compilation and Communication of Quality Improvement Information

Instructions

In Appendix H, the Quality Improvement Strategy must describe how the State compiles quality improvement information and the frequency with which the State communicates this information (in report or other forms) to waiver participants, families, waiver services providers, other interested parties and the public.

Periodic Evaluation and Revision of the QIS

Instructions

Describe the process to periodically evaluate and revise, as appropriate, the Quality Improvement Strategy.

This Appendix addresses the following financial elements of HCBS waiver operations: Financial Integrity and Accountability, Rates, Billings and Claims, Payments, Non-Federal Matching Funds, Exclusion of Medicaid Payment for Room and Board, Payment for Rent and Food Expenses of an Unrelated Live-In Caregiver, Participant Co-Payments for Waiver Services and Other Cost Sharing.

1. Financial Integrity and Accountability. This item focuses on how the state assures the integrity of payments that are made for waiver services. It focuses specifically, on post-payment audit activities. The on-screen instructions explain everything that needs to be included in this item.

1. Quality Improvement: Financial Accountability

   Financial Accountability

   State financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver.

   Instructions: The QIS must describe how the state Medicaid Agency will determine that each waiver assurance (and its associated component elements) is met. The waiver assurance and component elements are listed above. For each component element, this description must include:

   • Activities or processes that are related to discovery and remediation, i.e., review, assessment or monitoring processes; who conducts the discovery or remediation activities and with what frequency. The information can be aggregated and analyzed to measure the overall system performance in meeting the waiver assurances. The types of information used to measure performance, should include relevant quality measures/indicators.
   • The entity or entities responsible for reviewing the results (data and information) of discovery and remediation activities to determine whether the performance of the system reflects compliance with the assurances; and,
   • The frequency at which system performance is measured.

   If the State does not have mechanisms currently in place to discover and remediate compliance with the respective waiver assurance, the State must provide (in item c) the timelines to design or implement methods for discovery and remediation related to the assurance that is currently non-operational. In this item, the state must provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

2. Rates, Billing and Claims
   1. Rate Determination Methods. Describe the methods that are employed to establish provider payment rates for waiver services and the entity or entities that are responsible for rate determination. Indicate any opportunity for public comment in the process for establishing rates. If different methods are employed for various types of services, the description may group services where the same method is employed.
   2. Flow of Billings. Describe the flow of billings for waiver services, specifying whether provider billings flow directly from providers to the State’s claims payment system or whether billings are routed through other intermediary entities. If billings flow through other intermediary entities, specify the entities.
   3. Certifying Public Expenditures. In this item select if Certified Public Expenditures are made for waiver services. If they are made, then specify if they are made by state and/or local agencies and as applicable, provide all requested information in the text boxes provided.
   4. Billing Validation Process. In this item billing validation refers to pre-payment and other processes planned to make certain that the provider’s billings for waiver services meets certain essential tests. Also, only valid billings are included in the state’s claim for federal financial participation.
   5. Billing and Claims Record Maintenance Requirement. This item does not require any action.
3. Payment
   1. Method of payments – MMIS. Indicate whether payments to providers are made exclusively through the state’s Medicaid Management Information System. If not, then select one of the other choices. Also, select the first choice because the Medicaid agency must always retain the capability to make direct payment to a provider whether or not it has other methods for making payment.
   2. Direct payment. For this item select each mechanism used to make payments to waiver providers.
   3. Supplemental or Enhanced Payments. Indicate whether supplement or enhanced payments are made to the providers of waiver services. If they are, then provide the additional information specified.
   4. Payments to Public Providers. Indicate whether payment is made to public providers for the provision of waiver services. If so specify the public providers that receive payment and the waiver services that they furnish. Also complete Item I-3-e.
   5. Amount of Payment to Public Providers. When payment is made to public providers for the provision of waiver services, indicate whether public providers are paid the same amount as other providers of the same service. If not, then indicate whether payments to public providers in the aggregate exceed their reasonable costs of providing waiver services.
   6. Provider Retention of Payments. Indicate whether providers receive and retain 100 percent of the amount that the state claims for waiver services. In the case of §1915(b)/§1915(c) concurrent waivers, select the second choice and indicate whether managed care entities receive and retain 100 percent of the amount that the state claims for capitation payments to such entities.
   7. Additional Payment Arrangements. This item addresses additional payment arrangements that may be employed for waiver services. Two of these arrangements (reassignment of payment to a governmental agency and Organized Health Care Delivery System) are recognized exceptions to the requirement contained in §1902(a) (32) of the Act that prohibits State payments for Medicaid services to any entity other than the provider of the service.
4. Non-Federal Matching Funds
   1. State Level Sources of the Non-Federal Share of Computable Waiver Costs. Select the applicable state sources of the non-Federal share of computable waiver costs. Where specified, provide the additional information about these sources.
   2. Local or Other Sources of the Non-Federal Share of Computable Waiver Costs. This item is not applicable if local entities do not provide any part of the non-federal share through IGT or CPE. If local entities provide part of the non-federal share then follow the instructions on the screen to complete the item.
   3. Information Concerning Certain Sources of Funds. In this item, select if any of these sources make-up part of the non-federal share. If any are used, describe the source of funds in detail.
5. Exclusion of Medicaid Payment for Room and Board. Select whether waiver services are furnished in residential settings other than the participant’s own private residence. If so, complete Item I-5-b. Otherwise, do not complete I-5-b.
6. Payment for Rent and Food Expenses of an Unrelated Live-In Caregiver. Select whether the waiver provides for the payment of the rent and food expenses of an unrelated caregiver. If so, explain: (a) the method that is used to apportion the additional costs of rent and food attributable to the unrelated live-in personal caregiver that are incurred by the individual served on the waiver and (b) the method used to reimburse these costs that routes payment through the provider.
7. Participant Co-Payments for Waiver Services and Other Cost Sharing. This appendix specifies whether or not a state imposes co-payments or other cost sharing arrangements. The amount of these charges is subject to federal limits and no provider may deny services to a participant who unable to pay the cost sharing. Both items I-7-a and I-7-b must be completed. Follow the onscreen instructions.

In this Appendix the state has to demonstrate to CMS that the waiver is cost neutral for each year that the waiver is in effect. Appendix J-1 provides a composite overview of the demonstration that the waiver is cost neutral. Appendix J-2 contains the basis of the estimates of the factors that make up the cost neutrality demonstration.

1. Composite Overview and Demonstration of Cost-Neutrality Formula. Complete the fields in Cols. 3, 5 and 6 in the following table for each waiver year. The fields in Cols. 4, 7 and 8 are auto-calculated based on entries in Cols 3, 5, and 6. The fields in Col. 2 are auto-calculated using the Factor D data from the J-2d Estimate of Factor D tables. Col. 2 fields will be populated ONLY when the Estimate of Factor D tables in J-2d have been completed.
2. Derivation of Estimates.
   1. Number Of Unduplicated Participants Served. The number of unduplicated participants is essential in calculating Factor D for the cost-neutrality formula and it will automatically populate from Appendix B-3-a. If the state serves participants at more than one-level of care then the sum of participants from those columns must equal the total number of unduplicated participants identified in Appendix B-3-a. . In the case of a new waiver or a new waiver to replace an approved waiver, the rows for waiver years 4 and 5 may be deleted from the table.
   2. Average Length of Stay. Average length of stay is a statistic that describes the average number of days in a year that an individual participates in the waiver. This statistic is calculated by dividing the number of “enrolled days” by all waiver participants by the unduplicated number of waiver participants. Describe the basis of the estimate of the average length of stay on the waiver by participants in item J-2-a.
   3. Derivation of Estimates for Each Factor. In this item, the derivation of estimates for each factor is described. The state should include any necessary or important references to supporting documentation for how these values were derived. Describe the bases of the estimates of Factors D, D’, G, and G’.
   4. Estimate of Factor D. If the state selected N/A in Main 1-G then they will complete Appendix J-2-d-i but if the appendix operates concurrently with other waivers, the on-line waiver application will go directly to Appendix J-2-d-ii. When the waiver operates concurrently, additional information is requested about whether or not the service is covered in the capitation rate paid to managed care entities or will be paid outside the capitation rate. Complete the tables for each year the waiver will be operating and the on-line application will calculate Factor D and automatically populate the value into Appendix J-1.