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1915b4-ffs-application Preprint Overhaul Instrutions – Outline

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Application for
Section 1915(b) (4) Waiver
Fee-for-Service
Selective Contracting Program
June, 2012
v1.0
2
Table of Contents
Facesheet 3
Section A – Waiver Program Description 4
Part I: Program Overview
Tribal Consultation 4
Program Description 4
Waiver Services 4
A. Statutory Authority 4
B. Delivery Systems 4
C. Restriction of Freedom-of-Choice 5
D. Populations Affected by Waiver 5
Part II: Access, Provider Capacity and Utilization Standards
A. Timely Access Standards 6
B. Provider Capacity Standards 6
C. Utilization Standards 6
Part III: Quality
A. Quality Standards and Contract Monitoring 7
B. Coordination and Continuity-of-Care Standards 7
Part IV: Program Operations
A. Beneficiary Information 8
B. Individuals with Special Needs 8
Section B – Waiver Cost-Effectiveness and Efficiency 8
3
Application for Section 1915(b) (4) Waiver
Fee-for-Service (FFS) Selective Contracting Program
Facesheet
The State of requests a waiver/amendment under the authority of section
1915(b) of the Act. The Medicaid agency will directly operate the waiver.
The name of the waiver program is _________________________________
______________
.
Type of request. This is:
___
___
___
___
___
___
___
___
____
dd
____________.
(___) ________, (___) _____________
_________________.
(List each program name if the waiver authorizes more than one program.).
an initial request for new waiver. All sections are filled.
a request to amend an existing waiver, which modifies Section/Part ____
a renewal request
Section A is:
replaced in full
carried over with no changes
changes noted in BOLD.
Section B is:
replaced in full
changes noted in BOLD.
Effective Dates: This waiver/renewal/amendment is requested for a period of years
beginning ____________and ending
State Contact: The State contact person for this waiver is ______________________ and can
be reached by telephone at or fax at , or e-mail at
(List for each program)
4
Section A – Waiver Program Description
Part I: Program Overview
Tribal Consultation:
Describe the efforts the State has made to ensure that Federally-recognized tribes in the State are
aware of and have had the opportunity to comment on this waiver proposal (if additional space is
needed, please supplement your answer with a Word attachment).
Program Description:
Provide a brief description of the proposed selective contracting program or, if this is a request to
amend an existing selective contracting waiver, the history of and changes requested to the
existing program. Please include the estimated number of enrollees served throughout the
waiver (if additional space is needed, please supplement your answer with a Word attachment).
Waiver Services:
Please list all existing State Plan services the State will provide through this selective contracting
waiver (if additional space is needed, please supplement your answer with a Word attachment).
5
A. Statutory Authority
1. Waiver Authority. The State is seeking authority under the following subsection of
1915(b):
___
2. Sections Waived. The State requests a waiver of these sections of 1902 of the Social
Security Act:
a.___
___
___.
___
___
__
___
___
___
___
___
___
1915(b) (4) - FFS Selective Contracting program
Section 1902(a) (1) - Statewideness
b. Section 1902(a) (10) (B) - Comparability of Services
c Section 1902(a) (23) - Freedom of Choice
d. Other Sections of 1902 – (please specify)
B. Delivery Systems
1. Reimbursement. Payment for the selective contracting program is:
the same as stipulated in the State Plan
_ is different than stipulated in the State Plan (please describe)
2. Procurement. The State will select the contractor in the following manner:
Competitive procurement
Open cooperative procurement
Sole source procurement
Other (please describe)
C. Restriction of Freedom of Choice
1. Provider Limitations.
Beneficiaries will be limited to a single provider in their service area.
Beneficiaries will be given a choice of providers in their service area.
(NOTE: Please indicate the area(s) of the State where the waiver program will be
implemented)
2. State Standards.
Detail any difference between the state standards that will be applied under this waiver and those
detailed in the State Plan coverage or reimbursement documents (if additional space is needed,
please supplement your answer with a Word attachment).
___
___
___
___
___
___
___
___
___
___
___
___
___
___
6
D. Populations Affected by Waiver
(May be modified as needed to fit the State’s specific circumstances)
1. Included Populations. The following populations are included in the waiver:
Section 1931 Children and Related Populations
Section 1931 Adults and Related Populations
Blind/Disabled Adults and Related Populations
Blind/Disabled Children and Related Populations
Aged and Related Populations
Foster Care Children
Title XXI CHIP Children
2. Excluded Populations. Indicate if any of the following populations are excluded from
participating in the waiver:
Dual Eligibles
Poverty Level Pregnant Women
Individuals with other insurance
Individuals residing in a nursing facility or ICF/MR
Individuals enrolled in a managed care program
Individuals participating in a HCBS Waiver program
American Indians/Alaskan Natives
7
___
__
_
___
\
Special Needs Children (State Defined). Please provide this definition.
Individuals receiving retroactive eligibility
Other (Please define):
Part II: Access, Provider Capacity and Utilization Standards
A. Timely Access Standards
Describe the standard that the State will adopt (or if this is a renewal or amendment of an
existing selective contracting waiver, provide evidence that the State has adopted)
defining timely Medicaid beneficiary access to the contracted services, i.e., what
constitutes timely access to the service?
1. How does the State measure (or propose to measure) the timeliness of Medicaid
beneficiary access to the services covered under the selective contracting program (if
additional space is needed, please supplement your answer with a Word attachment)?
2. Describe the remedies the State has or will put in place in the event that Medicaid
beneficiaries are unable to access the contracted service in a timely fashion (if
additional space is needed, please supplement your answer with a Word attachment).
8
B. Provider Capacity Standards
Describe how the State will ensure (or if this is a renewal or amendment of an existing
selective contracting waiver, provide evidence that the State has ensured) that its
selective contracting program provides a sufficient supply of contracted providers to meet
Medicaid beneficiaries’ needs.
1. Provide a detailed capacity analysis of the number of providers (e.g., by type, or
number of beds for facility-based programs), or vehicles (by type, per contractor for
non-emergency transportation programs), needed per location or region to assure
sufficient capacity under the selective contracting program (if additional space is
needed, please supplement your answer with a Word attachment).
9
2. Describe how the State will evaluate and ensure on an ongoing basis that providers
are appropriately distributed throughout the geographic regions covered by the
selective contracting program so that Medicaid beneficiaries have sufficient and
timely access throughout the regions affected by the program (if additional space is
needed, please supplement your answer with a Word attachment).
B. Utilization Standards
Describe the State’s utilization standards specific to the selective contracting program.
1. How will the State (or if this is a renewal or amendment of an existing selective
contracting waiver, provide evidence that the State) regularly monitor(s) the selective
contracting program to determine appropriate Medicaid beneficiary utilization, as
defined by the utilization standard described above (if additional space is needed,
please supplement your answer with a Word attachment)?
10
2. Describe the remedies the State has or will put in place in the event that Medicaid
beneficiary utilization falls below the utilization standards described above (if
additional space is needed, please supplement your answer with a Word attachment).
Part III: Quality
A. Quality Standards and Contract Monitoring
1. Describe the State’s quality measurement standards specific to the selective contracting
program (if additional space is needed, please supplement your answer with a Word
attachment).
a. Describe how the State will (or if this is a renewal or amendment of an existing
selective contracting waiver, provide evidence that the State):
i. Regularly monitor(s) the contracted providers to determine compliance with the
State’s quality standards for the selective contracting program.
ii. Take(s) corrective action if there is a failure to comply.
11
2. Describe the State’s contract monitoring process specific to the selective contracting
program (if additional space is needed, please supplement your answer with a Word
attachment).
a. Describe how the State will (or if this is a renewal or amendment of an existing
selective contracting waiver, provide evidence that the State):
i. Regularly monitor(s) the contracted providers to determine compliance with the
contractual requirements of the selective contracting program.
ii. Take(s) corrective action if there is a failure to comply.
B. Coordination and Continuity of Care Standards
Describe how the State assures that coordination and continuity of care is not negatively
impacted by the selective contracting program (if additional space is needed, please
supplement your answer with a Word attachment).
___
12
Part IV: Program Operations
A. Beneficiary Information
Describe how beneficiaries will get information about the selective contracting program (if
additional space is needed, please supplement your answer with a Word attachment).
B. Individuals with Special Needs.
The State has special processes in place for persons with special needs
(Please provide detail).
13
Section B – Waiver Cost-Effectiveness & Efficiency
Efficient and economic provision of covered care and services:
1. Provide a description of the State’s efficient and economic provision of covered care and
services (if additional space is needed, please supplement your answer with a Word
attachment).
2. Project the waiver expenditures for the upcoming waiver period.
Year 1 from: __/__/____
________
0.00%
________
__/__/____
________
0.00%
________
________
________
________
________
________
__/__/____
________
________
to __/__/____
Trend rate from current expenditures (or historical figures): %
Projected pre-waiver cost
Projected Waiver cost
Difference:
Year 2 from: __/__/____ to
Trend rate from current expenditures (or historical figures): %
Projected pre-waiver cost
Projected Waiver cost
Difference:
Year 3 (if applicable) from: __/__/____ to __/__/____
(For renewals, use trend rate from previous year and claims data from the CMS-64)
Projected pre-waiver cost
Projected Waiver cost
Difference:
Year 4 (if applicable) from: __/__/____ to
(For renewals, use trend rate from previous year and claims data from the CMS-64)
Projected pre-waiver cost
Projected Waiver cost
Difference:
14
Year 5 (if applicable) from: __/__/____ __/__/____
________
________
________
to
(For renewals, use trend rate from previous year and claims data from the CMS-64)
Projected pre-waiver cost
Projected Waiver cost
Difference:
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