Fillable 1915i-application 1915 Final Template 1-3-17

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1915i-application 1915 Final Template 1-3-17

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State: §1915(i) State plan HCBS State plan Attachment 3.1–i:
TN: Page
1
Effective: Approved: Supersedes:
1915(i) State plan Home and Community-Based Services
Administration and Operation
The sta
te implements the optional 1915(i) State plan Home and Community-Based Services (HCBS) benefit
for elderly and disabled individuals as set forth below.
1. Services.
(Specify the state’s service title(s) for the HCBS defined under “Services” and listed in
Attachment 4.19-B):
2. Concurrent Operation with Other Programs. (Indicate whether this benefit will operate
concurrently with another Medicaid authority):
Select one:
Not applicable
Applicable
Check the applicable authority or authorities:
Services furnished under the provisions of §1915(a)(1)(a) of the Act. The State contracts with
a Managed Care Organization(s) (MCOs) and/or prepaid inpatient health plan(s) (PIHP) or
prepaid ambulatory health plan(s) (PAHP) under the provisions of §1915(a)(1) of the Act for the
delivery of 1915(i) State plan HCBS. Participants may voluntarily elect to receive waiver and
other services through such MCOs or prepaid health plans. Contracts with these health plans are
on file at the State Medicaid agency. Specify:
(a) the MCOs and/or health plans that furnish services under the provisions of §1915(a)(1);
(b) the geographic areas served by these plans;
(c) the specific 1915(i) State plan HCBS furnished by these plans;
(d) how payments are made to the health plans; and
(e) whether the 1915(a) contract has been submitted or previously approved.
Waiver(s) authorized under §1915(b) of the Act.
Specify the §1915(b) waiver program and indicate whether a §1915(b) waiver application has been
submitted or previously approved:
Specify the §1915(b) authorities under which this program operates (
check each that applies
):
§1915(b)(1) (mandated enrollment to
managed care)
§1915(b)(3) (employ cost savings to furnish
additional services)
§1915(b)(2) (central broker)
number of providers)
A program operated under §1932(a) of the Act.
Specify the nature of the State Plan benefit and indicate whether the State Plan Amendment has
been submitted or previously approved:
A program authorized under §1115 of the Act. Specify the program:
State: §1915(i) State plan HCBS State plan Attachment 3.1–i:
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2
Effective: Approved: Supersedes:
3. State Medicaid Agency
(SMA) Line of Authority for Operating the State plan HCBS.
Benefit-
(Select one):
The State plan HCBS benefit is operated by the SMA. Specify the SMA division/unit that has
line authority for the operation of the program (select one):
The Medical Assistance Unit (name of unit):
Another division/unit within the SMA that is separate from the Medical Assistance Unit
(name of division/unit)
This includes
administrations/divisions
under the umbrella
agency that have been
identified as the Single
State Medicaid Agency.
The State plan HCBS benefit is operated by (name of agency)
a separate agency of the state that is not a division/unit of the Medicaid agency. In accordance
with 42 CFR §431.10, the Medicaid agency exercises administrative discretion in the
administration and supervision of the State plan HCBS benefit and issues policies, rules and
regulations related to the State plan HCBS benefit. The interagency agreement or memorandum
of understanding that sets forth the authority and arrangements for this delegation of authority is
available through the Medicaid agency to CMS upon request.
State: §1915(i) State plan HCBS State plan Attachment 3.1–i:
TN: Page
3
Effective: Approved: Supersedes:
4. Distributi
on of State plan HCBS Operational and Administrative Functions.
(By checking this box the state assures that): When the Medicaid agency does not directly conduct an
administrative 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. When a function is performed by an
agency/entity other than the Medicaid agency, the agency/entity performing that function does not substitute
its own judgment for that of the Medicaid agency with respect to the application of policies, rules and
regulations. Furthermore, the Medicaid Agency assures that it maintains accountability for the performance
of any operational, contractual, or local regional entities. In the following table, specify the entity or entities
that have responsibility for conducting each of the operational and administrative functions listed (check
each that applies):
(Check all agencies and/or entities that perform each function):
Function
Medicaid
Agency
Other State
Operating
Agency
Contracted
Entity
Local Non-
State Entity
1 Individual State plan HCBS enrollment
2 Eligibility evaluation
3 Review of participant service plans
4 Prior authorization of State plan HCBS
5 Utilization management
6 Qualified provider enrollment
7 Execution of Medicaid provider agreement
8 Establishment of a consistent rate
methodology for each State plan HCBS
9 Rules, policies, procedures, and
information development governing the State
plan HCBS benefit
10Quality assurance and quality improvement
activities
(Specify, as numbered above, the agencies/entities (other than the SMA) that perform each function):
State: §1915(i) State plan HCBS State plan Attachment 3.1–i:
TN: Page
4
Effective: Approved: Supersedes:
(By
checking the following boxes the State assures that):
5.
Conflict of Interest Standards. T
he state assures the independence of persons performing
evaluations, assessments, and plans of care. Written conflict of interest standards ensure, at a minimum,
that persons performing these functions are not:
• related by blood or marriage to the individual, or any paid caregiver of the individual
• financially responsible for the individual
• empowered to make financial or health-related decisions on behalf of the individual
• providers of State plan HCBS for the individual, or those who have interest in or are employed by
a provider of State plan HCBS; except, at the option of the state, when providers are given
responsibility to perform assessments and plans of care because such individuals are the only
willing and qualified entity in a geographic area, and the state devises conflict of interest
protections. (If the state chooses this option, specify the conflict o f interest protections the state
will implement):
6.
Fair Hearings and Appeals.
The state assures that
individuals have opportunities for fair hearings
and appeals in accordance with
42 CFR 431 Subpart E.
7.
No
FFP f
or Room and Board.
The state has methodology to prevent
claims for Federal financial
participation for room and board in State plan
HCBS.
8.
Non-duplication of services.
State plan HCBS will not be provided
to
an
individual at the same
time as another service that is the same in nature and
scope regardless
of source, including F
ederal, s
tate,
local, and private
entities. For
habilitation services, the state
includes within the record of
each individual
an explanation
that these services do not include special education
and
related services defined in the
Individuals with Disabilities
Education
Improvement
Act
of 2004 that
otherwise are
available to the
individual
through a local education agency, or vocational
rehabilitation services that
otherwise are
available
to the
individual
through a program funded under §110 of the Rehabilitation Act of 1973.
State: §1915(i) State plan HCBS State plan Attachment 3.1–i:
TN: Page
5
Effective: Approved: Supersedes:
Number Served
1. Projected Number of Unduplicated Individuals To Be Served Annually.
(Specify for year one. Years 2-5 optional):
Annual Period
From
To
Projected Number of Participants
Year 1
Year 2
Year 3
Year 4
Year 5
2. Annual Reporting. (By checking this box the state agrees to): annually report the actual number of
unduplicated individuals served and the estimated number of individuals for the following year.
Financial Eligibility
1. Medicaid Eligible. (By checking this box the state assures that): Individuals receiving State plan
HCBS are included in an eligibility group that is covered under the State’s Medicaid Plan and have
income that does not exceed 150% of the Federal Poverty Line (FPL). (This election does not include the
optional categorically needy eligibility group specified at §1902(a)(10)(A)(ii)(XXII) of the Social
Security Act. States that want to adopt the §1902(a)(10)(A)(ii)(XXII) eligibility category make the
election in Attachment 2.2-A of the state Medicaid plan.)
2. Medically Needy
(Select one):
The State does not provide State plan HCBS to the medically needy.
The State provides State plan HCBS to the medically needy. (Select one):
The state elects to disregard the requirements section of 1902(a)(10)(C)(i)(III) of the
Social Security Act relating to community income and resource rules for the medically
needy. When a state makes this election, individuals who qualify as medically needy on the
basis of this election receive only 1915(i) services.
The state does not elect to disregard the requirements at section 1902(a)(10)(C)(i)(III) of
the Social Security Act.
State: §1915(i) State plan HCBS State plan Attachment 3.1–i:
TN: Page
6
Effective: Approved: Supersedes:
1. Res
ponsibility for
Performing Evaluations / Reevaluations. Eligibility for the State pl
an HCBS benefit
must be determined through an independent evaluation of each individual). Independent
evaluations/reevaluations to determine whether applicants are eligible for the State plan HCBS benefit are
performed (Select one):
Directly by the Medicaid agency
By Other (specify State agency or entity under contract with the State Medicaid agency):
2. Qualifications of Individuals Performing Evaluation/Reevaluation. The independent evaluation is
performed by an agent that is independent and qualified. There are qualifications (that are reasonably
related to performing evaluations) for the individual responsible for evaluation/reevaluation of needs-
based eligibility for State plan HCBS. (Specify qualifications):
3. Process for Performing Evaluation/Reevaluation. Describe the process for evaluating whether
individuals meet the needs-based State plan HCBS eligibility criteria and any instrument(s) used to make
this determination. If the reevaluation process differs from the evaluation process, describe the differences:
4. Reevaluation Schedule. (By checking this box the state assures that): Needs-based eligibility
reevaluations are conducted at least every twelve months.
5. Needs-based HCBS Eligibility Criteria. (By checking this box the state assures that): Needs-based
criteria are used to evaluate and reevaluate whether an individual is eligible for State plan HCBS.
The criteria take into account the individual’s support needs, and may include other risk factors: (Specify
the needs-based criteria):
Evaluation/Reevaluation of Eligibility
State: §1915(i) State plan HCBS State plan Attachment 3.1–i:
TN: Page
7
Effective: Approved: Supersedes:
6. Needs-based Institutional and Waiver Criteria. (By checking this box the state assures that):
There are needs-based criteria for receipt of institutional services and participation in certain waivers that
are more stringent than the criteria above for receipt of State plan HCBS. If the state has revised
institutional level of care to reflect more stringent needs-based criteria, individuals receiving institutional
services and participating in certain waivers on the date that more stringent criteria become effective are
exempt from the new criteria until such time as they no longer require that level of care. (Complete chart
below to summarize the needs-based criteria for State Plan HCBS and corresponding more-stringent
criteria for each of the following institutions):
State plan HCBS needs-
based eligibility criteria
NF (& NF LOC**
waivers)
ICF/IID (& ICF/IID
LOC waivers)
Applicable Hospital* (&
Hospital LOC waivers)
*Long Term Care/Chronic Care Hospital
**LOC= level of care
7. Target Group(s). The state elects to target this 1915(i) State plan HCBS benefit to a specific
population based on age, disability, diagnosis, and/or eligibility group. With this election, the state will
operate this program for a period of 5 years. At least 90 days prior to the end of this 5 year period, the
state may request CMS renewal of this benefit for additional 5-year terms in accordance with
1915(i)(7)(C) and 42 CFR 441.710(e)(2). (Specify target group(s)):
Option for Phase-in of Services and Eligibility. If the state elects to target this 1915(i) State plan
HCBS benefit, it may limit the enrollment of individuals or the provision of services to enrolled individuals
in accordance with 1915(i)(7)(B)(ii) and 42 CFR 441.745(a)(2)(ii) based upon criteria described in a phase-
in plan, subject to CMS approval. At a minimum, the phase-in plan must describe: (1) the criteria used to
limit enrollment or service delivery; (2) the rationale for phasing-in services and/or eligibility; and (3)
timelines and benchmarks to ensure that the benefit is available statewide to all eligible individuals within
the initial 5-year approval.
(Specify the phase-in plan):
(By checking the following box the State assures that):
8. Adjustment Authority. The state will notify CMS and the public at least 60 days before exercising
the option to modify needs-based eligibility criteria in accord with 1915(i)(1)(D)(ii).
9. Reasonable Indication of Need for Services. In order for an individual to be determined to need the
1915(i) State plan HCBS benefit, an individual must require: (a) the provision of at least one 1915(i)
service, as documented in the person-centered service plan, and (b) the provision of 1915(i) services at
least monthly or, if the need for services is less than monthly, the participant requires regular monthly
monitoring which must be documented in the person-centered service plan. Specify the state’s policies
concerning the reasonable indication of the need for 1915(i) State plan HCBS:
i.
Minimum number of services.
The minimum number of 1915(i) State plan services (one or more) that an individual must
require in order to be determined to need the 1915(i) State plan HCBS benefit is:
ii.
Frequency of services. The state requires (select one):
The provision of 1915(i) services at least monthly
Monthly monitoring of the individual when services are furnished on a less than monthly
basis
If the state also requires a minimum frequency for the provision of 1915(i) services other than
monthly (e.g., quarterly), specify the frequency:
Home and Community-Based Settings
State: §1915(i) State plan HCBS State plan Attachment 3.1–i:
TN: Page
8
Effective: Approved: Supersedes:
(By checking the following box the State assures that):
1. Home and Community-Based Settings. The State plan HCBS benefit will be furnished to
individuals who reside and receive HCBS in their home or in the community, not in an institution.
(Explain how residential and non-residential settings in this SPA comply with Federal home and
community-based settings requirements at 42 CFR 441.710(a)(1)-(2) and associated CMS
guidance. Include a description of the settings where individuals will reside and where individuals will
receive HCBS, and how these settings meet the Federal home and community-based settings
requirements, at the time of submission and in the future):
(Note: In the Quality Improvement Strategy (QIS) portion of this SPA, the state will be prompted to
include how the state Medicaid agency will monitor to ensure that all settings meet federal home and
community-based settings requirements, at the time of this submission and ongoing.)
Person-Centered Planning & Service Delivery
State: §1915(i) State plan HCBS State plan Attachment 3.1–i:
TN: Page
9
Effective: Approved: Supersedes:
(By checking the following boxes the stat
e assures th
at):
1. There is an independent assessment of individuals determined to be eligible for the State plan HCBS
benefit. The assessment meets federal requirements at 42 CFR §441.720.
2. Based on the independent assessment, there is a person-centered service plan for each individual
determined to be eligible for the State plan HCBS benefit. The person-centered service plan is developed
using a person-centered service planning process in accordance with 42 CFR §441.725(a), and the written
person-centered service plan meets federal requirements at 42 CFR §441.725(b).
3. The person-centered service plan is reviewed, and revised upon reassessment of functional need as
required under 42 CFR §441.720, at least every 12 months, when the individual’s circumstances or needs
change significantly, and at the request of the individual.
4. Responsibility for Face-to-Face Assessment of an Individual’s Support Needs and Capabilities.
There are educational/professional qualifications (that are reasonably related to performing assessments) of
the individuals who will be responsible for conducting the independent assessment, including specific
training in assessment of individuals with need for HCBS. (Specify qualifications):
5. Responsibility for Development of Person-Centered Service Plan. There are qualifications (that are
reasonably related to developing service plans) for persons responsible for the development of the
individualized, person-centered service plan. (Specify qualifications):
6. Supporting the Participant in Development of Person-Centered Service Plan. Supports and
information are made available to the participant (and/or the additional parties specified, as appropriate) to
direct and be actively engaged in the person-centered service plan development process. (Specify: (a) the
supports and information made available, and (b) the participant’s authority to determine who is included
in the process):
7. Informed Choice of Providers. (Describe how participants are assisted in obtaining information about
and selecting from among qualified providers of the 1915(i) services in the person-centered service plan):
8. Process for Making Person-Centered Service Plan Subject to the Approval of the Medicaid Agency.
(Describe the process by which the person-centered service plan is made subject to the approval of the
Medicaid agency):
9. Maintenance of Person-Centered Service Plan Forms. Written copies or electronic facsimiles of service
plans are maintained for a minimum period of 3 years as required by 45 CFR §74.53. Service plans are
maintained by the following (check each that applies):
Medicaid agency
Operating agency
Case manager
Other (specify):
State: §1915(i) State plan HCBS State plan Attachment 3.1–i:
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10
Effective: Approved: Supersedes:
Services
1. State plan HCBS. (Complete the following table for each service. Copy table as needed):
Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the
state plans to cover):
Service Title:
Service Definition (Scope):
Additional needs-based criteria for receiving the service, if applicable (specify):
Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240,
services available to any categorically needy recipient cannot be less in amount, duration and scope
than those services available to a medically needy recipient, and services must be equal for any
individual within a group. States must also separately address standard state plan service questions
related to sufficiency of services.
(Choose each that applies):
Categorically needy (specify limits):
Medically needy (specify limits):
Provider Qualifications (For each type of provider. Copy rows as needed):
Provider Type
(Specify):
License
(Specify):
Certification
(Specify):
Other Standard
(Specify):
Verification of Provider Qualifications (For each provider type listed above. Copy rows as
needed):
Provider Type
(Specify):
Entity Responsible for Verification
(Specify):
Frequency of Verification
(Specify):
Service Delivery Method. (Check each that applies):
Participant-directed
Provider managed
State: §1915(i) State plan HCBS State plan Attachment 3.1–i:
TN: Page
11
Effective: Approved: Supersedes:
2.
Policies Concerning Payment for State plan HCBS Furnished by Relatives, Legally Responsible
Individuals, and Legal Guardians. (By checking this box the state assures that): There are policies
pe
rtaining to payment the state makes to qualified persons furnishing State plan HCBS, who are relativ
es
o
f the individual. There are additional policies and controls if the state makes payment to qualifie
d
le
gally responsible individuals or legal guardians who provide State Plan HCBS. (Specify (a) who may
be
paid to provide State plan HCBS; (b) the specific State plan HCBS that can be provided; (c) how the state
en
sures that the provision of services by such persons is in the best interest of the individual; (d) th
e
sta
te’s strategies for ongoing monitoring of services provided by such persons; (e) the controls to ensur
e
that payments are made only for services rendered; and (f) if legally responsible individuals may provide
p
ersonal care or similar services, the policies to determine and ensure that the services are extraordinar
y
(
over and above that which would ordinarily be provided by a legally responsible individual)
:
State: §1915(i) State plan HCBS State plan Attachment 3.1–i:
TN: Page
12
Effective: Approved: Supersedes:
Participant-Direction of Services
Definition: Participant-direction means self-direction of services per §1915(i)(1)(G)(iii).
Election of Participant-Direction. (Select one):
The state does not offer opportunity for participant-direction of State plan HCBS.
Every participant in State plan HCBS (or the participant’s representative) is afforded the
opportunity to elect to direct services. Alternate service delivery methods are available for
participants who decide not to direct their services.
Participants in State plan HCBS (or the participant’s representative) are afforded the opportunity
to direct some or all of their services, subject to criteria specified by the state. (Specify criteria):
1. Description of Participant-Direction. (Provide an overview of the opportunities for participant-
direction under the State plan HCBS, including: (a) the nature of the opportunities afforded; (b)
how participants may take advantage of these opportunities; (c) the entities that support
individuals who direct their services and the supports that they provide; and, (d) other relevant
information about the approach to participant-direction):
2. Limited Implementation of Participant-Direction. (Participant direction is a mode of service
delivery, not a Medicaid service, and so is not subject to state wideness requirements. Select
one):
Participant direction is available in all geographic areas in which State plan HCBS are available.
Participant-direction is available only to individuals who reside in the following geographic areas
or political subdivisions of the state. Individuals who reside in these areas may elect self-directed
service delivery options offered by the state, or may choose instead to receive comparable
services through the benefit’s standard service delivery methods that are in effect in all
geographic areas in which State plan HCBS are available. (Specify the areas of the state affected
by this option):
3. Participant-Directed Services. (Indicate the State plan HCBS that may be participant-directed and
the authority offered for each. Add lines as required):
Participant-Directed Service
Employer
Authority
Budget
Authority
4. Fi
nancial Management. (Select one)
:
Financial Management is not furnished. Standard Medicaid payment mechanisms are used.
Financial Management is furnished as a Medicaid administrative activity necessary for
administration of the Medicaid State plan.
State: §1915(i) S
tate plan HCBS State plan Attachment 3.1–i:
TN: Page
13
Effective: Approved: Supersedes:
5.
Participant–Directed Person-Centered Service Plan. (By checking this box the state assures
that): Based on the independent assessment required under 42 CFR §441.720, the individualized
person-centered service plan is developed jointly with the individual, meets federal requirements
at 42 CFR §441.725, and: Specifies the State plan HCBS that the individual will be responsible
for directing; Identifies the methods by which the individual will plan, direct or control services,
including whether the individual will exercise authority over the employment of service providers
and/or authority over expenditures from the individualized budget; Includes appropriate risk
management techniques that explicitly recognize the roles and sharing of responsibilities in
obtaining services in a self-directed manner and assures the appropriateness of this plan based
upon the resources and support needs of the individual; Describes the process for facilitating
voluntary and involuntary transition from self-direction including any circumstances under which
transition out of self-direction is involuntary. There must be state procedures to ensure the
continuity of services during the transition from self-direction to other service delivery methods;
and Specifies the financial management supports to be provided.
State: §1915(i) State plan HCBS State plan Attachment 3.1–i:
TN: Page
14
Effective: Approved: Supersedes:
7. Voluntary and Involuntary Termination of Participant-Direction.
(Describe how the state
facilitates an individual’s transition from participant-direction, and specify any circumstances
when transition is involuntary):
8. Opportunities for Participant-Direction
a. Participant–Employer Authority
(individual can select, manage, and dismiss State plan HCBS
providers). (Select one):
The state does not offer opportunity for participant-employer authority.
Participants may elect participant-employer Authority (Check each that applies):
Participant/Co-Employer. The participant (or the participant’s representative) functions as
the co-employer (managing employer) of workers who provide waiver services. An agency is
the common law employer of participant-selected/recruited staff and performs necessary
payroll and human resources functions. Supports are available to assist the participant in
conducting employer-related functions.
Participant/Common Law Employer. The participant (or the participant’s representative) is
the common law employer of workers who provide waiver services. An IRS-approved
Fiscal/Employer Agent functions as the participant’s agent in performing payroll and other
employer responsibilities that are required by federal and state law. Supports are available to
assist the participant in conducting employer-related functions.
b. Participant–Budget Authority (individual directs a budget that does not result in payment for
medical assistance to the individual). (Select one):
The state does not offer opportunity for participants to direct a budget.
Participants may elect Participant–Budget Authority.
Participant-Directed Budget. (Describe in detail the method(s) that are used to establish the
amount of the budget over which the participant has authority, including the method for
calculating the dollar values in the budget based on reliable costs and service utilization, is
applied consistently to each participant, and is adjusted to reflect changes in individual
assessments and service plans. Information about these method(s) must be made publicly
available and included in the person-centered service plan.):
Expenditure Safeguards. (Describe the safeguards that have been established for the timely
prevention of the premature depletion of the participant-directed budget or to address potential
service delivery problems that may be associated with budget underutilization and the entity (or
entities) responsible for implementing these safeguards.
State: §1915(i) State plan HCBS State plan Attachment 3.1-i:
TN: Page
15
Effective: Approved: Supersedes:
Quality Improvement Strategy
Quality Measures
(Describe the state’s quality improvement strategy. For each requirement, and lettered sub-requirement,
complete the table below):
1. Service plans a) address assessed needs of 1915(i) participants; b) are updated annually; and (c
document choice of services and providers.
2. Eligibility Requirements: (a) an evaluation for 1915(i) State plan HCBS eligibility is provided
to all applicants for whom there is reasonable indication that 1915(i) services may be needed in
the future; (b) the processes and instruments described in the approved state plan for
determining 1915(i) eligibility are applied appropriately; and (c) the 1915(i) benefit eligibility
of enrolled individuals is reevaluated at least annually or if more frequent, as specified in the
approved state plan for 1915(i) HCBS.
3. Providers meet required qualifications.
4. Settings meet the home and community-based setting requirements as specified in this SPA and
in accordance with 42 CFR 441.710(a)(1) and (2).
5. The SMA retains authority and responsibility for program operations and oversight.
6. The SMA maintains financial accountability through payment of claims for services that are
authorized and furnished to 1915(i) participants by qualified providers.
7. The state identifies, addresses, and seeks to prevent incidents of abuse, neglect, and
exploitation, including the use of restraints.
(Table repeats for each measure for each requirement and lettered sub-requirement above.)
Requirement
Discovery
Discovery
Evidence
(Performance
Measure)
Discovery
Activity
(Source of Data &
sample size)
Monitoring
Responsibilities
(Agency or entity
that conducts
discovery activities)
State: §1915(i) State plan HCBS State plan Attachment 3.1-i:
TN: Page
16
Effective:
Approved: Supersedes:
Requirement
Frequency
Remediation
Remediation
Responsibilities
(Who corrects,
analyzes, and
aggregates
remediation
activities; required
timeframes for
remediation)
Frequency
(of Analysis and
Aggregation)
System Improvement
(Describe the process for systems improvement as a result of aggregated discovery and remediation activities.)
1. Methods for Analyzing Data and Prioritizing Need for System Improvement
2. Roles and Responsibilities
3. Frequency
4. Method for Evaluatin
g Effec
tiveness of System Changes
State: §1915(i) State plan HCBS State plan Attachment 4.19–B:
TN:
Effective: Approved: Supersedes:
Methods and Standards for Establishing Payment Rates
1. Services Provided Under Section 1915(i) of the Social Security Act. For each optional service, describe
t
he methods and standards used to set the associated payment rate. (Check each that applies, and describ
e
m
ethods and standards to set rates
):
HCBS Case Management
HCBS Homemaker
HCBS Home Health Aide
HCBS Personal Care
HCBS Adult Day Health
HCBS Habilitation
HCBS Respite Care
For Individuals with Chronic Mental Illness, the following services:
HCBS Day Treatment or Other Partial Hospitalization Services
HCBS Psychosocial Rehabilitation
HCBS Clinic Services (whether or not furnished in a facility for CMI)
Other Services (specify below)
State: §1915(i) State plan HCBS State plan Attachment 2.2-A:
TN:
Effective: Approved: Supersedes:
Groups Covered
Optional Groups other than the Medically Needy
In addition to providing State plan HCBS to individuals described in 1915(i)(1), the state may also
cover the optional categorically needy eligibility group of individuals described in
1902(a)(10)(A)(ii)(XXII) who are eligible for HCBS under the needs-based criteria established under
1915(i)(1)(A) and have income that does not exceed 150% of the FPL, or who are eligible for HCBS
under a waiver approved for the state under Section 1915(c), (d) or (e) or Section 1115 (even if they
are not receiving such services), and who do not have income that exceeds 300% of the supplemental
security income benefit rate. See 42 CFR § 435.219. (Select one):
No. Does not apply. State does not cover optional categorically needy groups.
Yes. State covers the following optional categorically needy groups.
(Select all that apply):
(a) Individuals not otherwise eligible for Medicaid who meet the needs-based criteria of the
1915(i) benefit, have income that does not exceed 150% of the federal poverty level, and
will receive 1915(i) services. There is no resource test for this group. Methodology used:
(Select one):
SSI. The state uses the following less restrictive 1902(r)(2) income disregards for
this group. (Describe, if any):
OTHER (describe):
(b) Individuals who are eligible for home and community-based services under a waiver
approved for the State under section 1915(c), (d) or (e) (even if they are not receiving such
services), and who do not have income that exceeds 300% of the supplemental security
income benefit rate.
Income limit: (Select one):
300% of the SSI/FBR
Less than 300% of the SSI/FBR (Specify): _____%
State: §1915(i) State plan HCBS State plan Attachment 2.2-A:
TN:
Effective: Approved: Supersedes:
Specify the applicable 1915(c), (d), or (e) waiver or waivers for which these
individuals would be eligible: (Specify waiver name(s) and number(s)):
(c) Individuals eligible for 1915(c), (d) or (e) -like services under an approved 1115 waiver.
The income and resource standards and methodologies are the same as the applicable
approved 1115 waiver.
Specify the 1115 waiver demonstration or demonstrations for which these individuals
would be eligible. (Specify demonstration name(s) and number(s)):
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-1188. The time required to complete this information collection is
estimated to average 114 hours per response, including the time to review instructions, search existing
data resources, and gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-
05, and Baltimore, Maryland 21244-1850.
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1915i-application 1915 Final Template 1-3-17

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Completed 1 November 2019

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