Application for a §1915(c) Home and Community-
Based Services Waiver
PURPOSE OF THE HCBS WAIVER PROGRAM
The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in §1915(c) of the Social Security
Act. The program permits a state to furnish an array of home and community-based services that assist Medicaid beneficiaries to
live in the community and avoid institutionalization. The State has broad discretion to design its waiver program to address the
needs of the waivers target population. Waiver services complement and/or supplement the services that are available to
participants through the Medicaid State plan and other federal, state and local public programs as well as the supports that families
and communities provide.
The Centers for Medicare & Medicaid Services (CMS) recognizes that the design and operational features of a waiver program
will vary depending on the specific needs of the target population, the resources available to the state, service delivery system
structure, state goals and objectives, and other factors. A State has the latitude to design a waiver program that is cost-effective
and employs a variety of service delivery approaches, including participant direction of services.
Request for a Renewal to a §1915(c) Home and Community-Based Services
Waiver
1. Major Changes
Describe any significant changes to the approved waiver that are being made in this renewal application:
This renewal will make the following substantive changes to the waiver:
1. Incorporate eQ Health Solutions as the contracted entity responsible for care coordination of Model Waiver recipients.
2. Update performance measures in the following appendices: A,B,C,D,F,G & I
3. Update waiver services to remove the Assistive Technology and Service Evaluation service.
Application for a §1915(c) Home and Community-Based Services Waiver
1. Request Information (1 of 3)
The State of Florida requests approval for a Medicaid home and community-based services (HCBS) waiver under the
authority of §1915(c) of the Social Security Act (the Act).
A.
Program Title (optional - this title will be used to locate this waiver in the finder):
Model Waiver
B.
Type of Request: renewal
Requested Approval Period:(For new waivers requesting five year approval periods, the waiver must serve individuals
who are dually eligible for Medicaid and Medicare.)
3 years 5 years
Original Base Waiver Number: FL.40166
Waiver Number:FL.40166.R06.00
Draft ID: FL.018.06.00
C.
Type of Waiver (select only one):
Model Waiver
D.
Proposed Effective Date: (mm/dd/yy)
07/01/20
Approved Effective Date: 07/01/20
E.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 1 of 118
06/24/2020
1. Request Information (2 of 3)
Level(s) of Care. This waiver is requested in order to provide home and community-based waiver services to individuals
who, but for the provision of such services, would require the following level(s) of care, the costs of which would be
reimbursed under the approved Medicaid state plan (check each that applies):
Hospital
Select applicable level of care
Hospital as defined in 42 CFR §440.10
If applicable, specify whether the state additionally limits the waiver to subcategories of the hospital level of
care:
Inpatient psychiatric facility for individuals age 21 and under as provided in42 CFR §440.160
Nursing Facility
Select applicable level of care
Nursing Facility as defined in 42 CFR ??440.40 and 42 CFR ??440.155
If applicable, specify whether the state additionally limits the waiver to subcategories of the nursing facility level
of care:
Institution for Mental Disease for persons with mental illnesses aged 65 and older as provided in 42 CFR
§440.140
Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) (as defined in 42 CFR
§440.150)
If applicable, specify whether the state additionally limits the waiver to subcategories of the ICF/IID level of care:
F.
1. Request Information (3 of 3)
Concurrent Operation with Other Programs. This waiver operates concurrently with another program (or programs)
approved under the following authorities
Select one:
Not applicable
Applicable
Check the applicable authority or authorities:
Services furnished under the provisions of §1915(a)(1)(a) of the Act and described in Appendix I
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)(2) (central broker)
§1915(b)(3) (employ cost savings to furnish additional services)
G.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 2 of 118
06/24/2020
§1915(b)(4) (selective contracting/limit 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 §1915(i) of the Act.
A program authorized under §1915(j) of the Act.
A program authorized under §1115 of the Act.
Specify the program:
Dual Eligiblity for Medicaid and Medicare.
Check if applicable:
This waiver provides services for individuals who are eligible for both Medicare and Medicaid.
H.
2. Brief Waiver Description
Brief Waiver Description. In one page or less, briefly describe the purpose of the waiver, including its goals, objectives,
organizational structure (e.g., the roles of state, local and other entities), and service delivery methods.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 3 of 118
06/24/2020
The Model Waiver is an existing waiver designed to delay or prevent institutionalization and allow recipients to maintain stable
health while living at home or in their community. The waiver’s purpose is to provide medically necessary services to eligible
children under 21 years of age who have degenerative spinocerebellar disease and are living at home or in their community.
Spinocerebellar degenerations are disorders in which the cerebellar and spinal motor and sensory systems undergo progressive
deterioration or impairment.
Services are also intended to permit eligible children to voluntarily transition from the nursing home into a less restrictive and
more integrated community setting when appropriate. As such, this waiver also serves eligible children under 21 years of age
that are medically fragile, and have resided in a skilled nursing facility for at least 60 consecutive days prior to entrance on the
waiver. Medically Fragile is defined as an individual who is medically complex and technologically dependent on medical
apparatus or procedures to sustain life, or are dependent on a heightened level of medical supervision to sustain life, and without
such services are likely to expire without warning.
The Model Waiver is a deeming waiver in which parental income is disregarded and the child is considered to be a family of one.
This type of waiver allows children who are otherwise ineligible for Medicaid to become Medicaid eligible for the waiver. Once
eligible for the waiver the child is eligible for all Medicaid State Plan services.
Model Waiver provides the following services to eligible recipients:
1. Respite care;
2. Environmental accessibility adaptations; and
3. Transition Case Management.
Model Waiver recipients are enrolled with Florida's Children's Medical Services (CMS) for their level of care determination.
Care coordination of Medicaid State Plan and Model Waiver services is conducted by a contracted vendor. The Model Waiver
does not reimburse for services available to recipients under Medicaid State Plan.
The Model Waiver has a maximum capacity of twenty recipients and a reserved capacity for fifteen children transitioning into
the community from a skilled nursing facility. The Model Waiver program is monitored by the Agency for Health Care
Administration (AHCA).
Florida Medicaid is responsible for assuring compliance with federal program requirements, developing Medicaid policy and for
reimbursing Medicaid providers. Medicaid also has operational responsibilities for the Model Waiver. Operational
responsibilities are coordinated with CMS.
Level of care recommendations for the Model Wavier and placement in a skilled nursing facility for children under the age of 21
is determined the Children's Multidisciplinary Assessment Team (CMAT). The CMAT team is an inter-agency coordinated
effort that includes AHCA, the Office of Family Safety in the Department of Children and Families (DCF), the Agency for
Persons with Disabilities (APD), and Children's Medical Services (CMS) in the Department of Health (DOH) as well as other
principal recipients named in the CMAT Statewide Operational Plan.
The DCF is responsible for determining Medicaid recipient financial eligibility, including Model waiver recipients. No dual
eligible are served in this waiver, as the waiver enables recipients who are not currently Medicaid eligible to access Medicaid
benefits as a family of one.
3. Components of the Waiver Request
The waiver application consists of the following components. Note: Item 3-E must be completed.
Waiver Administration and Operation. Appendix A specifies the administrative and operational structure of this
waiver.
A.
Participant Access and Eligibility. Appendix B specifies the target group(s) of individuals who are served in this waiver,
the number of participants that the state expects to serve during each year that the waiver is in effect, applicable Medicaid
eligibility and post-eligibility (if applicable) requirements, and procedures for the evaluation and reevaluation of level of
care.
B.
Participant Services. Appendix C specifies the home and community-based waiver services that are furnished through
the waiver, including applicable limitations on such services.
C.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 4 of 118
06/24/2020
Participant-Centered Service Planning and Delivery. Appendix D specifies the procedures and methods that the state
uses to develop, implement and monitor the participant-centered service plan (of care).
D.
Participant-Direction of Services. When the state provides for participant direction of services, Appendix E specifies the
participant direction opportunities that are offered in the waiver and the supports that are available to participants who
direct their services. (Select one):
Yes. This waiver provides participant direction opportunities. Appendix E is required.
No. This waiver does not provide participant direction opportunities. Appendix E is not required.
E.
Participant Rights. Appendix F specifies how the state informs participants of their Medicaid Fair Hearing rights and
other procedures to address participant grievances and complaints.
F.
Participant Safeguards. Appendix G describes the safeguards that the state has established to assure the health and
welfare of waiver participants in specified areas.
G.
Quality Improvement Strategy. Appendix H contains the Quality Improvement Strategy for this waiver.H.
Financial Accountability. Appendix I describes the methods by which the state makes payments for waiver services,
ensures the integrity of these payments, and complies with applicable federal requirements concerning payments and
federal financial participation.
I.
Cost-Neutrality Demonstration. Appendix J contains the state's demonstration that the waiver is cost-neutral.J.
4. Waiver(s) Requested
Comparability. The state requests a waiver of the requirements contained in §1902(a)(10)(B) of the Act in order to
provide the services specified in Appendix C that are not otherwise available under the approved Medicaid state plan to
individuals who: (a) require the level(s) of care specified in Item 1.F and (b) meet the target group criteria specified in
Appendix B.
A.
Income and Resources for the Medically Needy. Indicate 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 (select one):
Not Applicable
No
Yes
B.
Statewideness. Indicate whether the state requests a waiver of the statewideness requirements in §1902(a)(1) of the Act
(select one):
No
Yes
If yes, specify the waiver of statewideness that is requested (check each that applies):
Geographic Limitation. A waiver of statewideness is requested in order to furnish services under this waiver
only to individuals who reside in the following geographic areas or political subdivisions of the state.
Specify the areas to which this waiver applies and, as applicable, the phase-in schedule of the waiver by
geographic area:
Limited Implementation of Participant-Direction. A waiver of statewideness is requested in order to make
participant-direction of services as specified in Appendix E available only to individuals who reside in the
following geographic areas or political subdivisions of the state. Participants who reside in these areas may elect
to direct their services as provided by the state or receive comparable services through the service delivery
methods that are in effect elsewhere in the state.
Specify the areas of the state affected by this waiver and, as applicable, the phase-in schedule of the waiver by
geographic area:
C.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 5 of 118
06/24/2020
5. Assurances
In accordance with 42 CFR §441.302, the state provides the following assurances to CMS:
Health & Welfare: The state assures that necessary safeguards have been taken to protect the health and welfare of
persons receiving services under this waiver. These safeguards include:
As specified in Appendix C, adequate standards for all types of providers that provide services under this waiver;1.
Assurance that the standards of any state licensure or certification requirements specified in Appendix C are met
for services or for individuals furnishing services that are provided under the waiver. The state assures that these
requirements are met on the date that the services are furnished; and,
2.
Assurance that all facilities subject to §1616(e) of the Act where home and community-based waiver services are
provided comply with the applicable state standards for board and care facilities as specified in Appendix C.
3.
A.
Financial Accountability. The state assures financial accountability for funds expended for home and community-based
services and maintains and makes available to the Department of Health and Human Services (including the Office of the
Inspector General), the Comptroller General, or other designees, appropriate financial records documenting the cost of
services provided under the waiver. Methods of financial accountability are specified in Appendix I.
B.
Evaluation of Need: The state assures that it provides for an initial evaluation (and periodic reevaluations, at least
annually) of the need for a level of care specified for this waiver, when there is a reasonable indication that an individual
might need such services in the near future (one month or less) but for the receipt of home and community-based services
under this waiver. The procedures for evaluation and reevaluation of level of care are specified in Appendix B.
C.
Choice of Alternatives: The state assures that when an individual is determined to be likely to require the level of care
specified for this waiver and is in a target group specified in Appendix B, the individual (or, legal representative, if
applicable) is:
Informed of any feasible alternatives under the waiver; and,1.
Given the choice of either institutional or home and community-based waiver services. Appendix B specifies the
procedures that the state employs to ensure that individuals are informed of feasible alternatives under the waiver
and given the choice of institutional or home and community-based waiver services.
2.
D.
Average Per Capita Expenditures: The state assures that, for any year that the waiver is in effect, the average per capita
expenditures under the waiver will not exceed 100 percent of the average per capita expenditures that would have been
made under the Medicaid state plan for the level(s) of care specified for this waiver had the waiver not been granted. Cost-
neutrality is demonstrated in Appendix J.
E.
Actual Total Expenditures: The state assures that the actual total expenditures for home and community-based waiver
and other Medicaid services and its claim for FFP in expenditures for the services provided to individuals under the waiver
will not, in any year of the waiver period, exceed 100 percent of the amount that would be incurred in the absence of the
waiver by the state's Medicaid program for these individuals in the institutional setting(s) specified for this waiver.
F.
Institutionalization Absent Waiver: The state assures that, absent the waiver, individuals served in the waiver would
receive the appropriate type of Medicaid-funded institutional care for the level of care specified for this waiver.
G.
Reporting: The state assures that annually it will provide CMS with information concerning the impact of the waiver on
the type, amount and cost of services provided under the Medicaid state plan and on the health and welfare of waiver
participants. This information will be consistent with a data collection plan designed by CMS.
H.
Habilitation Services. The state assures that prevocational, educational, or supported employment services, or a
combination of these services, if provided as habilitation services under the waiver are: (1) not otherwise available to the
individual through a local educational agency under the Individuals with Disabilities Education Act (IDEA) or the
Rehabilitation Act of 1973; and, (2) furnished as part of expanded habilitation services.
I.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 6 of 118
06/24/2020
Services for Individuals with Chronic Mental Illness. The state assures that federal financial participation (FFP) will
not be claimed in expenditures for waiver services including, but not limited to, day treatment or partial hospitalization,
psychosocial rehabilitation services, and clinic services provided as home and community-based services to individuals
with chronic mental illnesses if these individuals, in the absence of a waiver, would be placed in an IMD and are: (1) age
22 to 64; (2) age 65 and older and the state has not included the optional Medicaid benefit cited in 42 CFR §440.140; or
(3) age 21 and under and the state has not included the optional Medicaid benefit cited in 42 CFR § 440.160.
J.
6. Additional Requirements
Note: Item 6-I must be completed.
Service Plan. In accordance with 42 CFR §441.301(b)(1)(i), a participant-centered service plan (of care) is developed for
each participant employing the procedures specified in Appendix D. All waiver services are furnished pursuant to the
service plan. The service plan describes: (a) the waiver services that are furnished to the participant, their projected
frequency and the type of provider that furnishes each service and (b) the other services (regardless of funding source,
including state plan services) and informal supports that complement waiver services in meeting the needs of the
participant. The service plan is subject to the approval of the Medicaid agency. Federal financial participation (FFP) is not
claimed for waiver services furnished prior to the development of the service plan or for services that are not included in
the service plan.
A.
Inpatients. In accordance with 42 CFR §441.301(b)(1)(ii), waiver services are not furnished to individuals who are in-
patients of a hospital, nursing facility or ICF/IID.
B.
Room and Board. In accordance with 42 CFR §441.310(a)(2), FFP is not claimed for the cost of room and board except
when: (a) provided as part of respite services in a facility approved by the state that is not a private residence or (b)
claimed as a portion of the rent and food that may be reasonably attributed to an unrelated caregiver who resides in the
same household as the participant, as provided in Appendix I.
C.
Access to Services. The state does not limit or restrict participant access to waiver services except as provided in
Appendix C.
D.
Free Choice of Provider. In accordance with 42 CFR §431.151, a participant may select any willing and qualified
provider to furnish waiver services included in the service plan unless the state has received approval to limit the number
of providers under the provisions of §1915(b) or another provision of the Act.
E.
FFP Limitation. In accordance with 42 CFR §433 Subpart D, FFP is not claimed for services when another third-party
(e.g., another third party health insurer or other federal or state program) is legally liable and responsible for the provision
and payment of the service. FFP also may not be claimed for services that are available without charge, or as free care to
the community. Services will not be considered to be without charge, or free care, when (1) the provider establishes a fee
schedule for each service available and (2) collects insurance information from all those served (Medicaid, and non-
Medicaid), and bills other legally liable third party insurers. Alternatively, if a provider certifies that a particular legally
liable third party insurer does not pay for the service(s), the provider may not generate further bills for that insurer for that
annual period.
F.
Fair Hearing: The state provides the opportunity to request a Fair Hearing under 42 CFR §431 Subpart E, to individuals:
(a) who are not given the choice of home and community-based waiver services as an alternative to institutional level of
care specified for this waiver; (b) who are denied the service(s) of their choice or the provider(s) of their choice; or (c)
whose services are denied, suspended, reduced or terminated. Appendix F specifies the state's procedures to provide
individuals the opportunity to request a Fair Hearing, including providing notice of action as required in 42 CFR §431.210.
G.
Quality Improvement. The state operates a formal, comprehensive system to ensure that the waiver meets the assurances
and other requirements contained in this application. Through an ongoing process of discovery, remediation and
improvement, the state assures the health and welfare of participants by monitoring: (a) level of care determinations; (b)
individual plans and services delivery; (c) provider qualifications; (d) participant health and welfare; (e) financial oversight
and (f) administrative oversight of the waiver. The state further assures that all problems identified through its discovery
processes are addressed in an appropriate and timely manner, consistent with the severity and nature of the problem.
During the period that the waiver is in effect, the state will implement the Quality Improvement Strategy specified in
Appendix H.
H.
Public Input. Describe how the state secures public input into the development of the waiver:I.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 7 of 118
06/24/2020
This is a request to renew a waiver that was previously approved. During the period of the original application the State
maintained ongoing communication with stakeholders, beneficiaries, and their families. Additional input was solicited
from the Department of Health (DOH), Children's Medical Services (CMS) to determine and establish medically
appropriate services for the target population. The State conducted a 30-day public comment period from February 24,
2020 to March 24, 2020 to solicit feedback and input from stakeholders. The State received public comments related to
expanding waiver eligibility. No actions were taken based on these public comments, as expanding eligibility would
require legislative authority. No tribal comments were received.
Notice to Tribal Governments. The state assures that it has notified in writing all federally-recognized Tribal
Governments that maintain a primary office and/or majority population within the State of the State's intent to submit a
Medicaid waiver request or renewal request to CMS at least 60 days before the anticipated submission date is provided by
Presidential Executive Order 13175 of November 6, 2000. Evidence of the applicable notice is available through the
Medicaid Agency.
J.
Limited English Proficient Persons. The state assures that it provides meaningful access to waiver services by Limited
English Proficient persons in accordance with: (a) Presidential Executive Order 13166 of August 11, 2000 (65 FR 50121)
and (b) Department of Health and Human Services "Guidance to Federal Financial Assistance Recipients Regarding Title
VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons" (68 FR 47311 -
August 8, 2003). Appendix B describes how the state assures meaningful access to waiver services by Limited English
Proficient persons.
K.
7. Contact Person(s)
The Medicaid agency representative with whom CMS should communicate regarding the waiver is:A.
Last Name:
Dalton
First Name:
Ann
Title:
Program Authorities Adminsitrator
Agency:
Agency for Health Care Administration
Address:
Bureau of Medicaid Policy
Address 2:
2727 Mahan Drive, Ft. Knox #3 MS #20
City:
Tallahassee
State:
Florida
Zip:
32308
Phone:
(850) 412-4223
Ext:
TTY
Fax:
(840) 414-1721
E-mail:
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 8 of 118
06/24/2020
If applicable, the state operating agency representative with whom CMS should communicate regarding the waiver is:B.
8. Authorizing Signature
This document, together with Appendices A through J, constitutes the state's request for a waiver under §1915(c) of the Social
Security Act. The state assures that all materials referenced in this waiver application (including standards, licensure and
certification requirements) are readily available in print or electronic form upon request to CMS through the Medicaid agency or,
if applicable, from the operating agency specified in Appendix A. Any proposed changes to the waiver will be submitted by the
Medicaid agency to CMS in the form of waiver amendments.
Upon approval by CMS, the waiver application serves as the state's authority to provide home and community-based waiver
services to the specified target groups. The state attests that it will abide by all provisions of the approved waiver and will
continuously operate the waiver in accordance with the assurances specified in Section 5 and the additional requirements specified
in Section 6 of the request.
Ann.Dalton@ahca.myflorida.com
Last Name:
First Name:
Title:
Agency:
Address:
Address 2:
City:
State:
Florida
Zip:
Phone:
Ext:
TTY
Fax:
E-mail:
Signature:
Beth Kidder
State Medicaid Director or Designee
Submission Date:
Jun 11, 2020
Note: The Signature and Submission Date fields will be automatically completed when the State
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 9 of 118
06/24/2020
Attachments
Attachment #1: Transition Plan
Check the box next to any of the following changes from the current approved waiver. Check all boxes that apply.
Replacing an approved waiver with this waiver.
Combining waivers.
Splitting one waiver into two waivers.
Eliminating a service.
Adding or decreasing an individual cost limit pertaining to eligibility.
Adding or decreasing limits to a service or a set of services, as specified in Appendix C.
Reducing the unduplicated count of participants (Factor C).
Adding new, or decreasing, a limitation on the number of participants served at any point in time.
Making any changes that could result in some participants losing eligibility or being transferred to another waiver
under 1915(c) or another Medicaid authority.
Making any changes that could result in reduced services to participants.
Specify the transition plan for the waiver:
Medicaid Director submits the application.
Last Name:
Kidder
First Name:
Beth
Title:
Deputy Secretary for Medicaid
Agency:
Agency for Health Care Administration
Address:
2727 Mahan Dr
Address 2:
City:
Tallahassee
State:
Florida
Zip:
32308
Phone:
(850) 412-4006
Ext:
TTY
Fax:
(840) 414-1721
E-mail:
Beth.kidder@ahca.myflorida.com
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 10 of 118
06/24/2020
Model Waiver recipients maintain full access to State Plan services designed to provide preventative and treatment services to
eligible children under the age of 21. Evaluations, such as assistive technology services evaluations, are a covered benefit
provided as medically necessary to eligible children under 21 years old through the State Plan. As a result, no transition plan is
needed for this population because this service is readily available. The Medicaid Agency will coordinate with the contracted
vendor's care coordinators to ensure that recipients are regularly made aware of all State Plan services that they may access as
medically necessary.
Attachment #2: Home and Community-Based Settings Waiver Transition Plan
Specify the state's process to bring this waiver into compliance with federal home and community-based (HCB) settings
requirements at 42 CFR 441.301(c)(4)-(5), and associated CMS guidance.
Consult with CMS for instructions before completing this item. This field describes the status of a transition process at the point in
time of submission. Relevant information in the planning phase will differ from information required to describe attainment of
milestones.
To the extent that the state has submitted a statewide HCB settings transition plan to CMS, the description in this field may
reference that statewide plan. The narrative in this field must include enough information to demonstrate that this waiver
complies with federal HCB settings requirements, including the compliance and transition requirements at 42 CFR 441.301(c)(6),
and that this submission is consistent with the portions of the statewide HCB settings transition plan that are germane to this
waiver. Quote or summarize germane portions of the statewide HCB settings transition plan as required.
Note that Appendix C-5 HCB Settings describes settings that do not require transition; the settings listed there meet federal HCB
setting requirements as of the date of submission. Do not duplicate that information here.
Update this field and Appendix C-5 when submitting a renewal or amendment to this waiver for other purposes. It is not
necessary for the state to amend the waiver solely for the purpose of updating this field and Appendix C-5. At the end of the state's
HCB settings transition process for this waiver, when all waiver settings meet federal HCB setting requirements, enter
"Completed" in this field, and include in Section C-5 the information on all HCB settings in the waiver.
The State assures that this waiver renewal will be subject to any provisions or requirements included in the State's most recent
home and community-based settings Statewide Transition Plan. The State will implement all CMS requiired changes by the end
of the transition period as outlined in the home and community-based settings Statewide Transition Plan.
Additional Needed Information (Optional)
Provide additional needed information for the waiver (optional):
Appendix A: Waiver Administration and Operation
State Line of Authority for Waiver Operation. Specify the state line of authority for the operation of the waiver (select
one):
The waiver is operated by the state Medicaid agency.
Specify the Medicaid agency division/unit that has line authority for the operation of the waiver program (select one):
The Medical Assistance Unit.
Specify the unit name:
The Bureau of Medicaid Policy
(Do not complete item A-2)
Another division/unit within the state Medicaid agency that is separate from the Medical Assistance Unit.
Specify the division/unit name. This includes administrations/divisions under the umbrella agency that has been
identified as the Single State Medicaid Agency.
1.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 11 of 118
06/24/2020
(Complete item A-2-a).
The waiver is operated by a separate agency of the state that is not a division/unit of the Medicaid agency.
Specify the division/unit name:
In accordance with 42 CFR §431.10, the Medicaid agency exercises administrative discretion in the administration
and supervision of the waiver and issues policies, rules and regulations related to the waiver. The interagency
agreement or memorandum of understanding that sets forth the authority and arrangements for this policy is available
through the Medicaid agency to CMS upon request. (Complete item A-2-b).
Appendix A: Waiver Administration and Operation
Oversight of Performance.
Medicaid Director Oversight of Performance When the Waiver is Operated by another Division/Unit within
the State Medicaid Agency. When the waiver is operated by another division/administration within the umbrella
agency designated as the Single State Medicaid Agency. Specify (a) the functions performed by that
division/administration (i.e., the Developmental Disabilities Administration within the Single State Medicaid
Agency), (b) the document utilized to outline the roles and responsibilities related to waiver operation, and (c) the
methods that are employed by the designated State Medicaid Director (in some instances, the head of umbrella
agency) in the oversight of these activities:
As indicated in section 1 of this appendix, the waiver is not operated by another division/unit within the
State Medicaid agency. Thus this section does not need to be completed.
a.
Medicaid Agency Oversight of Operating Agency Performance. When the waiver is not operated by the
Medicaid agency, specify the functions that are expressly delegated through a memorandum of understanding
(MOU) or other written document, and indicate the frequency of review and update for that document. Specify the
methods that the Medicaid agency uses to ensure that the operating agency performs its assigned waiver
operational and administrative functions in accordance with waiver requirements. Also specify the frequency of
Medicaid agency assessment of operating agency performance:
As indicated in section 1 of this appendix, the waiver is not operated by a separate agency of the State. Thus
this section does not need to be completed.
b.
2.
Appendix A: Waiver Administration and Operation
Use of Contracted Entities. Specify whether contracted entities perform waiver operational and administrative functions
on behalf of the Medicaid agency and/or the operating agency (if applicable) (select one):
Yes. Contracted entities perform waiver operational and administrative functions on behalf of the Medicaid
agency and/or operating agency (if applicable).
Specify the types of contracted entities and briefly describe the functions that they perform. Complete Items A-5 and
A-6.:
The State Medicaid Agency utilizes a Contracted Vendor (CV) for statewide care coordination for the Model
Waiver. Care coordination, another term for case management, includes such services as provider procurement, care
plan development, which serves as prior authorization of services, as well as the overall facilitation and management
of recipient care.
3.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 12 of 118
06/24/2020
No. Contracted entities do not perform waiver operational and administrative functions on behalf of the
Medicaid agency and/or the operating agency (if applicable).
Appendix A: Waiver Administration and Operation
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 (Select One):
Not applicable
Applicable - Local/regional non-state agencies perform waiver operational and administrative functions.
Check each that applies:
Local/Regional non-state public agencies perform waiver operational and administrative functions at the local
or regional level. There is an interagency agreement or memorandum of understanding between the State
and these agencies that sets forth responsibilities and performance requirements for these agencies that is
available through the Medicaid agency.
Specify the nature of these agencies and complete items A-5 and A-6:
Local/Regional non-governmental non-state entities conduct waiver operational and administrative functions
at the local or regional level. There is a contract between the Medicaid agency and/or the operating agency
(when authorized by the Medicaid agency) and each local/regional non-state entity that sets forth the
responsibilities and performance requirements of the local/regional entity. The contract(s) under which private
entities conduct waiver operational functions are available to CMS upon request through the Medicaid agency or
the operating agency (if applicable).
Specify the nature of these entities and complete items A-5 and A-6:
4.
Appendix A: Waiver Administration and Operation
Responsibility for Assessment of Performance of Contracted and/or Local/Regional Non-State Entities. Specify the
state agency or agencies responsible for assessing the performance of contracted and/or local/regional non-state entities in
conducting waiver operational and administrative functions:
Agency for Health Care Administration Bureau of Medicaid Quality
5.
Appendix A: Waiver Administration and Operation
Assessment Methods and Frequency. Describe the methods that are used to assess the performance of contracted and/or
local/regional non-state entities to ensure that they perform assigned waiver operational and administrative functions in
accordance with waiver requirements. Also specify how frequently the performance of contracted and/or local/regional
non-state entities is assessed:
6.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 13 of 118
06/24/2020
During each contract period, the Agency will provide monitoring and evaluation of the Vendor’s compliance with the
requirements of their contract.
1. The Agency will perform a monthly desk audits, reviews of all submitted reports from the Vendor, conduct telephonic
interviews and examine any data maintained by the Vendor.
2. The Contract Manager will perform an annual on-site monitoring and desk review monitoring.
Appendix A: Waiver Administration and Operation
Distribution of Waiver Operational and Administrative Functions. In the following table, specify the entity or entities
that have responsibility for conducting each of the waiver operational and administrative functions listed (check each that
applies):
In accordance with 42 CFR §431.10, when the Medicaid agency does not directly conduct a function, it supervises the
performance of the function and establishes and/or approves policies that affect the function. All functions not performed
directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. Note: More than
one box may be checked per item. Ensure that Medicaid is checked when the Single State Medicaid Agency (1) conducts
the function directly; (2) supervises the delegated function; and/or (3) establishes and/or approves policies related to the
function.
Function Medicaid Agency Contracted Entity
Participant waiver enrollment
Waiver enrollment managed against approved limits
Waiver expenditures managed against approved levels
Level of care evaluation
Review of Participant service plans
Prior authorization of waiver services
Utilization management
Qualified provider enrollment
Execution of Medicaid provider agreements
Establishment of a statewide rate methodology
Rules, policies, procedures and information development governing the waiver program
Quality assurance and quality improvement activities
7.
Appendix A: Waiver Administration and Operation
Quality Improvement: Administrative Authority of the Single State Medicaid
Agency
As a distinct component of the States quality improvement strategy, provide information in the following fields to detail the States
methods for discovery and remediation.
Methods for Discovery: Administrative Authority
The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver
program by exercising oversight of the performance of waiver functions by other state and local/regional non-state
agencies (if appropriate) and contracted entities.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance, complete
the following. Performance measures for administrative authority should not duplicate measures found in other
appendices of the waiver application. As necessary and applicable, performance measures should focus on:
i.
a.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 14 of 118
06/24/2020
Uniformity of development/execution of provider agreements throughout all geographic areas covered by
the waiver
Equitable distribution of waiver openings in all geographic areas covered by the waiver
Compliance with HCB settings requirements and other new regulatory components (for waiver actions
submitted on or after March 17, 2014)
Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to analyze
and assess progress toward the performance measure. In this section provide information on the method by which
each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions
drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Percentage of case file reviews completed by the Medicaid Agency on an annual basis that
comply with state requirements. Numerator: Number of case file reviews completed by the
Medicaid Agency on an annual basis that comply with state requirements Denominator:
Number of case files reviewed
Data Source (Select one):
Record reviews, on-site
If 'Other' is selected, specify:
Responsible Party for data
collection/generation(check
each that applies):
Frequency of data
collection/generation(check
each that applies):
Sampling Approach(check
each that applies):
State Medicaid
Agency
Weekly 100% Review
Operating Agency Monthly Less than 100%
Review
Sub-State Entity Quarterly Representative
Sample
Confidence
Interval =
Other
Specify:
Annually Stratified
Describe Group:
Continuously and
Ongoing
Other
Specify:
Other
Specify:
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 15 of 118
06/24/2020
Data Aggregation and Analysis:
Responsible Party for data aggregation
and analysis (check each that applies):
Frequency of data aggregation and
analysis(check each that applies):
State Medicaid Agency Weekly
Operating Agency Monthly
Sub-State Entity Quarterly
Other
Specify:
Annually
Continuously and Ongoing
Other
Specify:
If applicable, in the textbox below provide any necessary additional information on the strategies employed by the
State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
ii.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 16 of 118
06/24/2020
When reviewing case files, the Medicaid Agency reviews the following elements:
Hospitalization Frequency Measure- Collection of data of the number of overnight stays at hospitals and number
of emergency room vitas per yer for each recipient.
Plans of Care (POC) - POCs should be developed by the care coordinator within 30 days of the recipient’s
enrollment in the Model Waiver and 90 days prior to the activation of the annual renewal of the plan. The 90
days will allow time for the development of and submission to the Medicaid Agency for approval. The POC is
updated at least annually during a scheduled review of the recipient’s needs, preferences, goals, and health status.
Completed annually.
Beneficiary Surveys- Conducted by care coordinators and completed annually.
Interviews with waiver recipients/their families- Care Coordinators conduct these exploratory interviews. They
are designed to gather feedback and input. Information gained will be used to improve system performance and
quality of care. The information will also be used to identify, address, and prevent discrepancies between the
services that the Cost Plan and POC specify and services that the waiver recipients are receiving. During these
interviews, the Medicaid Agency also educates recipients and guardians on how to report concerns or incidences
of abuse, neglect, and exploitation. Due to the small total enrollment, the Medicaid Agency is interviewing 100%
of Model Waiver recipients annually.
Fiscal Review- Prior to yearly reviews of Model Waiver case files, all recipient Model Waiver billing data shall
be pulled to review usage patterns for recipients and providers. If unusual patterns are uncovered, providers are
referred to the Office of the Inspector General or the Bureau of Medicaid Program Integrity for review of possible
fraud and abuse. Completed annually.
Physician Referral & Diagnosis Confirmation Form- This is submitted upon application.
Application Form- This is submitted upon application.
The DCF Certification of Enrollment Status Form- This is submitted upon application.
Informed Consent Form - This is submitted upon application.
Periodic care coordinator conference call meetings- These conference call meetings serve various functions of
quality management. Training is always provided as part of the meeting. Topics such as expectation for client
contact and POC procedures have been reviewed. These meetings also serve as an opportunity for care
coordinators to obtain technical assistance from The Medcaid Agency as necessary. The calls also serve as a
course for identifying, addressing, and preventing problems with participant access to waiver services.
Methods for Remediation/Fixing Individual Problems
Describe the States method for addressing individual problems as they are discovered. Include information
regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on
the methods used by the state to document these items.
Multiple methods will be utilized to address and remediate individual problems. Interviews with Model Waiver
recipients and families will be conducted annually. These interviews are exploratory in nature, designed to gather
feedback and input. Information gained will be used to improve system performance and quality of care. The
information will also be used to identify, address, and prevent discrepancies between the services that the Cost
Plan and the POC specify and services that the waiver recipients are receiving. During these interviews, the
Medicaid Agency also educates recipients and guardians how to report concerns or incidence of abuse, neglect,
and exploitation. Due to the small total enrollment, the Medicaid Agency is interviewing 100% of Model Waiver
recipients annually.
i.
Remediation Data Aggregation
Remediation-related Data Aggregation and Analysis (including trend identification)
ii.
b.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 17 of 118
06/24/2020
Responsible Party(check each that applies):
Frequency of data aggregation and analysis
(check each that applies):
State Medicaid Agency Weekly
Operating Agency Monthly
Sub-State Entity Quarterly
Other
Specify:
Annually
Continuously and Ongoing
Other
Specify:
Timelines
When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design
methods for discovery and remediation related to the assurance of Administrative Authority that are currently non-
operational.
No
Yes
Please provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing
identified strategies, and the parties responsible for its operation.
c.
Appendix B: Participant Access and Eligibility
B-1: Specification of the Waiver Target Group(s)
Target Group(s). Under the waiver of Section 1902(a)(10)(B) of the Act, the state limits waiver services to one or more
groups or subgroups of individuals. Please see the instruction manual for specifics regarding age limits. In accordance
with 42 CFR §441.301(b)(6), select one or more waiver target groups, check each of the subgroups in the selected target
group(s) that may receive services under the waiver, and specify the minimum and maximum (if any) age of individuals
served in each subgroup:
Maximum Age
Target Group Included Target SubGroup Minimum Age
Maximum Age
Limit
No Maximum Age
Limit
Aged or Disabled, or Both - General
Aged
Disabled (Physical)
Disabled (Other)
Aged or Disabled, or Both - Specific Recognized Subgroups
Brain Injury
a.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 18 of 118
06/24/2020
Maximum Age
Target Group Included Target SubGroup Minimum Age
Maximum Age
Limit
No Maximum Age
Limit
HIV/AIDS
Medically Fragile
0
20
Technology Dependent
Intellectual Disability or Developmental Disability, or Both
Autism
Developmental Disability
Intellectual Disability
Mental Illness
Mental Illness
Serious Emotional Disturbance
Additional Criteria. The state further specifies its target group(s) as follows:
The individual must be diagnosed as having a degenerative spinocerebellar disease, or deemed medically fragile and
have resided in a skilled nursing facility for at least 60 consecutive days prior to enrollment.
Through the use of these services the goal is to delay or prevent hospitalization and allow these recipients to maintain
stable health while living at home in their community. Services are also intended to permit eligible children to voluntarily
transition from the nursing home into a less restrictive and more integrated community setting when appropriate.
The individual must be 20 years of age or younger;
The individual must be determined disabled using criteria established by the Social Security Administration (SSA);
The individual must meet an "at risk for hospitalization" level of care as determined by the Childrens Multidisciplinary
Assessment Team (CMAT);
The individual must be able to remain safely in the home with Home and Community Based Services provided through
Medicaid; or
The individual must meet the criteria to be deemed medically fragile.
b.
Transition of Individuals Affected by Maximum Age Limitation. When there is a maximum age limit that applies to
individuals who may be served in the waiver, describe the transition planning procedures that are undertaken on behalf of
participants affected by the age limit (select one):
Not applicable. There is no maximum age limit
The following transition planning procedures are employed for participants who will reach the waiver's
maximum age limit.
Specify:
Services authorized through the Model Waiver end on the recipient’s 21st birthday. The year prior to expiration of
eligibility the CMAT nurse will convene a transition meeting with the family, recipient, and eQ Health Solutions
care coordinator. During the transition meeting the recipient and the family will be apprised of services specific to
the needs identified.
c.
Appendix B: Participant Access and Eligibility
B-2: Individual Cost Limit (1 of 2)
Individual Cost Limit. The following individual cost limit applies when determining whether to deny home and a.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 19 of 118
06/24/2020
community-based services or entrance to the waiver to an otherwise eligible individual (select one). Please note that a state
may have only ONE individual cost limit for the purposes of determining eligibility for the waiver:
No Cost Limit. The state does not apply an individual cost limit. Do not complete Item B-2-b or item B-2-c.
Cost Limit in Excess of Institutional Costs. The state refuses entrance to the waiver to any otherwise eligible
individual when the state reasonably expects that the cost of the home and community-based services furnished to
that individual would exceed the cost of a level of care specified for the waiver up to an amount specified by the state.
Complete Items B-2-b and B-2-c.
The limit specified by the state is (select one)
A level higher than 100% of the institutional average.
Specify the percentage:
Other
Specify:
Institutional Cost Limit. Pursuant to 42 CFR 441.301(a)(3), the state refuses entrance to the waiver to any otherwise
eligible individual when the state reasonably expects that the cost of the home and community-based services
furnished to that individual would exceed 100% of the cost of the level of care specified for the waiver. Complete
Items B-2-b and B-2-c.
Cost Limit Lower Than Institutional Costs. The state refuses entrance to the waiver to any otherwise qualified
individual when the state reasonably expects that the cost of home and community-based services furnished to that
individual would exceed the following amount specified by the state that is less than the cost of a level of care
specified for the waiver.
Specify the basis of the limit, including evidence that the limit is sufficient to assure the health and welfare of waiver
participants. Complete Items B-2-b and B-2-c.
The cost limit specified by the state is (select one):
The following dollar amount:
Specify dollar amount:
The dollar amount (select one)
Is adjusted each year that the waiver is in effect by applying the following formula:
Specify the formula:
May be adjusted during the period the waiver is in effect. The state will submit a waiver
amendment to CMS to adjust the dollar amount.
The following percentage that is less than 100% of the institutional average:
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 20 of 118
06/24/2020
Specify percent:
Other:
Specify:
Appendix B: Participant Access and Eligibility
B-2: Individual Cost Limit (2 of 2)
Answers provided in Appendix B-2-a indicate that you do not need to complete this section.
Method of Implementation of the Individual Cost Limit. When an individual cost limit is specified in Item B-2-a,
specify the procedures that are followed to determine in advance of waiver entrance that the individual's health and welfare
can be assured within the cost limit:
b.
Participant Safeguards. When the state specifies an individual cost limit in Item B-2-a and there is a change in the
participant's condition or circumstances post-entrance to the waiver that requires the provision of services in an amount
that exceeds the cost limit in order to assure the participant's health and welfare, the state has established the following
safeguards to avoid an adverse impact on the participant (check each that applies):
The participant is referred to another waiver that can accommodate the individual's needs.
Additional services in excess of the individual cost limit may be authorized.
Specify the procedures for authorizing additional services, including the amount that may be authorized:
Other safeguard(s)
Specify:
c.
Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served (1 of 4)
Unduplicated Number of Participants. The following table specifies the maximum number of unduplicated participants
who are served in each year that the waiver is in effect. The state will submit a waiver amendment to CMS to modify the
number of participants specified for any year(s), including when a modification is necessary due to legislative
appropriation or another reason. The number of unduplicated participants specified in this table is basis for the cost-
neutrality calculations in Appendix J:
Waiver Year Unduplicated Number of Participants
Year 1
Table: B-3-a
a.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 21 of 118
06/24/2020
Waiver Year Unduplicated Number of Participants
20
Year 2
20
Year 3
20
Year 4
20
Year 5
20
Limitation on the Number of Participants Served at Any Point in Time. Consistent with the unduplicated number of
participants specified in Item B-3-a, the state may limit to a lesser number the number of participants who will be served at
any point in time during a waiver year. Indicate whether the state limits the number of participants in this way: (select one)
:
The state does not limit the number of participants that it serves at any point in time during a waiver
year.
The state limits the number of participants that it serves at any point in time during a waiver year.
The limit that applies to each year of the waiver period is specified in the following table:
Waiver Year
Maximum Number of Participants Served
At Any Point During the Year
Year 1
0
Year 2
0
Year 3
0
Year 4
0
Year 5
0
Table: B-3-b
b.
Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served (2 of 4)
Reserved Waiver Capacity. The state may reserve a portion of the participant capacity of the waiver for specified
purposes (e.g., provide for the community transition of institutionalized persons or furnish waiver services to individuals
experiencing a crisis) subject to CMS review and approval. The State (select one):
Not applicable. The state does not reserve capacity.
The state reserves capacity for the following purpose(s).
Purpose(s) the state reserves capacity for:
Purposes
Model Waiver
c.
Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served (2 of 4)
Purpose (provide a title or short description to use for lookup):
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 22 of 118
06/24/2020
Model Waiver
Purpose (describe):
The purpose of the reserved capacity is to aid in the sucessful transition of eligible children from skilled
nursing facilities to the community. Nursing Home Transition is the voluntary transfer of an eligible
Medicaid recipient who has been residing in a nursing home for a minimum of sixty (60) consecutive days,
into a less restrictive and more integrated community setting. The intent is to ensure that vacant slots are
available in the waiver when nursing home residents desire to transition in the community. Waiver
services minimize the barriers to transition and insure that the health and safety of the recipient is
maintained following transition.
Entrance to the waiver is based upon the date the application is submitted.
Describe how the amount of reserved capacity was determined:
The amount of reserved capacity was established by the State after assessing several factors. The State
examined current and historical nursing home utilization data for the 0 to 20 population. Interviews
conducted in September 2012 of parents of children who reside in a skilled nursing facility provide useful
data regarding the number of parents who are interested in transitioning their child into the home and
community. The determination for the amount of reserved capacity is reflective of the present need
identified.
The capacity that the State reserves in each waiver year is specified in the following table:
Waiver Year Capacity Reserved
Year 1
15
Year 2
15
Year 3
15
Year 4
15
Year 5
15
Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served (3 of 4)
Scheduled Phase-In or Phase-Out. Within a waiver year, the state may make the number of participants who are served
subject to a phase-in or phase-out schedule (select one):
The waiver is not subject to a phase-in or a phase-out schedule.
The waiver is subject to a phase-in or phase-out schedule that is included in Attachment #1 to Appendix
B-3. This schedule constitutes an intra-year limitation on the number of participants who are served in
the waiver.
d.
Allocation of Waiver Capacity.
Select one:
Waiver capacity is allocated/managed on a statewide basis.
Waiver capacity is allocated to local/regional non-state entities.
Specify: (a) the entities to which waiver capacity is allocated; (b) the methodology that is used to allocate capacity
e.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 23 of 118
06/24/2020
and how often the methodology is reevaluated; and, (c) policies for the reallocation of unused capacity among
local/regional non-state entities:
Selection of Entrants to the Waiver. Specify the policies that apply to the selection of individuals for entrance to the
waiver:
Entrants must meet the following qualifications to eligible for the Model Waiver:
•The individual must be 20 years of age or younger;
•The individual must be determined disabled using criteria established by the Social Security Administration (SSA);
•The individual must meet an "at risk for hospitalization" level of care as determined by the Children’s Multidisciplinary
Assessment Team (CMAT);
•The individual must be able to remain safely in the home with Home and Community Based Services provided through
Medicaid; or
•The individual must meet the criteria to be deemed medically fragile and reside 60 consecutive days in a skilled nursing
facility.
Parents, Caregivers, or Guardians can make an informed choice to receive home and community based care in lieu of
nursing facility care.
f.
Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served - Attachment #1 (4 of 4)
Answers provided in Appendix B-3-d indicate that you do not need to complete this section.
Appendix B: Participant Access and Eligibility
B-4: Eligibility Groups Served in the Waiver
State Classification. The state is a (select one):
§1634 State
SSI Criteria State
209(b) State
1.
Miller Trust State.
Indicate whether the state is a Miller Trust State (select one):
No
Yes
2.
a.
Medicaid Eligibility Groups Served in the Waiver. Individuals who receive services under this waiver are eligible under
the following eligibility groups contained in the state plan. The state applies all applicable federal financial participation
limits under the plan. Check all that apply:
Eligibility Groups Served in the Waiver (excluding the special home and community-based waiver group under 42 CFR
§435.217)
Low income families with children as provided in §1931 of the Act
SSI recipients
Aged, blind or disabled in 209(b) states who are eligible under 42 CFR §435.121
Optional state supplement recipients
Optional categorically needy aged and/or disabled individuals who have income at:
Select one:
b.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 24 of 118
06/24/2020
100% of the Federal poverty level (FPL)
% of FPL, which is lower than 100% of FPL.
Specify percentage:
Working individuals with disabilities who buy into Medicaid (BBA working disabled group as provided in
§1902(a)(10)(A)(ii)(XIII)) of the Act)
Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in
§1902(a)(10)(A)(ii)(XV) of the Act)
Working individuals with disabilities who buy into Medicaid (TWWIIA Medical Improvement Coverage
Group as provided in §1902(a)(10)(A)(ii)(XVI) of the Act)
Disabled individuals age 18 or younger who would require an institutional level of care (TEFRA 134 eligibility
group as provided in §1902(e)(3) of the Act)
Medically needy in 209(b) States (42 CFR §435.330)
Medically needy in 1634 States and SSI Criteria States (42 CFR §435.320, §435.322 and §435.324)
Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the state
plan that may receive services under this waiver)
Specify:
Special home and community-based waiver group under 42 CFR §435.217) Note: When the special home and
community-based waiver group under 42 CFR §435.217 is included, Appendix B-5 must be completed
No. The state does not furnish waiver services to individuals in the special home and community-based waiver
group under 42 CFR §435.217. Appendix B-5 is not submitted.
Yes. The state furnishes waiver services to individuals in the special home and community-based waiver group
under 42 CFR §435.217.
Select one and complete Appendix B-5.
All individuals in the special home and community-based waiver group under 42 CFR §435.217
Only the following groups of individuals in the special home and community-based waiver group under 42
CFR §435.217
Check each that applies:
A special income level equal to:
Select one:
300% of the SSI Federal Benefit Rate (FBR)
A percentage of FBR, which is lower than 300% (42 CFR §435.236)
Specify percentage:
A dollar amount which is lower than 300%.
Specify dollar amount:
Aged, blind and disabled individuals who meet requirements that are more restrictive than the SSI
program (42 CFR §435.121)
Medically needy without spend down in states which also provide Medicaid to recipients of SSI (42
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 25 of 118
06/24/2020
CFR §435.320, §435.322 and §435.324)
Medically needy without spend down in 209(b) States (42 CFR §435.330)
Aged and disabled individuals who have income at:
Select one:
100% of FPL
% of FPL, which is lower than 100%.
Specify percentage amount:
Other specified groups (include only statutory/regulatory reference to reflect the additional groups in
the state plan that may receive services under this waiver)
Specify:
Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (1 of 7)
In accordance with 42 CFR §441.303(e), Appendix B-5 must be completed when the state furnishes waiver services to individuals
in the special home and community-based waiver group under 42 CFR §435.217, as indicated in Appendix B-4. Post-eligibility
applies only to the 42 CFR §435.217 group.
Use of Spousal Impoverishment Rules. Indicate whether spousal impoverishment rules are used to determine eligibility
for the special home and community-based waiver group under 42 CFR §435.217:
Note: For the period beginning January 1, 2014 and extending through September 30, 2019 (or other date as required by
law), the following instructions are mandatory. The following box should be checked for all waivers that furnish waiver
services to the 42 CFR §435.217 group effective at any point during this time period.
Spousal impoverishment rules under §1924 of the Act are used to determine the eligibility of individuals with a
community spouse for the special home and community-based waiver group. In the case of a participant with a
community spouse, the state uses spousal post-eligibility rules under §1924 of the Act.
Complete Items B-5-e (if the selection for B-4-a-i is SSI State or §1634) or B-5-f (if the selection for B-4-a-i is 209b
State) and Item B-5-g unless the state indicates that it also uses spousal post-eligibility rules for the time periods
before January 1, 2014 or after September 30, 2019 (or other date as required by law).
Note: The following selections apply for the time periods before January 1, 2014 or after September 30, 2019 (or other
date as required by law) (select one).
Spousal impoverishment rules under §1924 of the Act are used to determine the eligibility of individuals with a
community spouse for the special home and community-based waiver group.
In the case of a participant with a community spouse, the state elects to (select one):
Use spousal post-eligibility rules under §1924 of the Act.
(Complete Item B-5-b (SSI State) and Item B-5-d)
Use regular post-eligibility rules under 42 CFR §435.726 (SSI State) or under §435.735 (209b State)
(Complete Item B-5-b (SSI State). Do not complete Item B-5-d)
Spousal impoverishment rules under §1924 of the Act are not used to determine eligibility of individuals with a
community spouse for the special home and community-based waiver group. The state uses regular post-
eligibility rules for individuals with a community spouse.
(Complete Item B-5-b (SSI State). Do not complete Item B-5-d)
a.
Appendix B: Participant Access and Eligibility
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 26 of 118
06/24/2020
B-5: Post-Eligibility Treatment of Income (2 of 7)
Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018.
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. Payment for home and community-based waiver services is
reduced by the amount remaining after deducting the following allowances and expenses from the waiver participant's
income:
Allowance for the needs of the waiver participant (select one):
The following standard included under the state plan
Select one:
SSI standard
Optional state supplement standard
Medically needy income standard
The special income level for institutionalized persons
(select one):
300% of the SSI Federal Benefit Rate (FBR)
A percentage of the FBR, which is less than 300%
Specify the percentage:
A dollar amount which is less than 300%.
Specify dollar amount:
A percentage of the Federal poverty level
Specify percentage:
Other standard included under the state Plan
Specify:
The following dollar amount
Specify dollar amount:
If this amount changes, this item will be revised.
The following formula is used to determine the needs allowance:
Specify:
Other
Specify:
i.
b.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 27 of 118
06/24/2020
The maintenance needs allowance is equal to the individual's total income as determined under the post
eligibility process which includes income that is placed in a Miller trust.
Allowance for the spouse only (select one):
Not Applicable
The state provides an allowance for a spouse who does not meet the definition of a community spouse in
§1924 of the Act. Describe the circumstances under which this allowance is provided:
Specify:
Specify the amount of the allowance (select one):
SSI standard
Optional state supplement standard
Medically needy income standard
The following dollar amount:
Specify dollar amount:
If this amount changes, this item will be revised.
The amount is determined using the following formula:
Specify:
ii.
Allowance for the family (select one):
Not Applicable (see instructions)
AFDC need standard
Medically needy income standard
The following dollar amount:
Specify dollar amount:
The amount specified cannot exceed the higher of the need standard for a
family of the same size used to determine eligibility under the state's approved AFDC plan or the medically
needy income standard established under 42 CFR §435.811 for a family of the same size. If this amount
changes, this item will be revised.
The amount is determined using the following formula:
Specify:
Other
Specify:
iii.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 28 of 118
06/24/2020
Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified
in 42 §CFR 435.726:
Health insurance premiums, deductibles and co-insurance chargesa.
Necessary medical or remedial care expenses recognized under state law but not covered under the state's
Medicaid plan, subject to reasonable limits that the state may establish on the amounts of these expenses.
b.
Select one:
Not Applicable (see instructions)Note: If the state protects the maximum amount for the waiver participant,
not applicable must be selected.
The state does not establish reasonable limits.
The state establishes the following reasonable limits
Specify:
iv.
Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (3 of 7)
Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018.
Regular Post-Eligibility Treatment of Income: 209(B) State.
Answers provided in Appendix B-4 indicate that you do not need to complete this section and therefore this section
is not visible.
c.
Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (4 of 7)
Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018.
Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules
The state uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the
contribution of a participant with a community spouse toward the cost of home and community-based care if it determines
the individual's eligibility under §1924 of the Act. There is deducted from the participant's monthly income a personal
needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the state
Medicaid Plan. The state must also protect amounts for incurred expenses for medical or remedial care (as specified
below).
Allowance for the personal needs of the waiver participant
(select one):
SSI standard
Optional state supplement standard
Medically needy income standard
The special income level for institutionalized persons
A percentage of the Federal poverty level
i.
d.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 29 of 118
06/24/2020
Specify percentage:
The following dollar amount:
Specify dollar amount:
If this amount changes, this item will be revised
The following formula is used to determine the needs allowance:
Specify formula:
Other
Specify:
Personal needs allowance is defined as:
For enrollees living in an assisted living facility, the personal needs allowance is calculated according to the
following formula: Three meals per day and the semi-private room rate (ALF Basic Room and Board Rate) +
20% of the Federal Poverty Level (FPL).
For community waiver participants not residing in the assisted living setting, the personal needs allowance
will equal the participant's income up to the 300% SSI amount. In addition, excess income is defined as the
recipient’s income after deductions for personal needs allowance, spousal impoverishment allowance, and
reasonable costs of incurred medical and remedial care as detailed in 42 CFR. For community waiver
residents all income up to the 300% SSI income limit is protected.
As a Miller Income Trust state, Florida requires waiver applicants to place income over the 300% SSI
income level into an approved income trust. Any income placed in the required income trust will be
included in the excess income or patient responsibility calculation. Patient responsibility is collected by the
LTC plan and applied against home and community-based service costs only. Plans are required to report
patient responsibility collections to the state. The collections are reviewed during the annual plan
reconciliation to verify the application of the patient responsibility funds to reduce home and community
based services only.
If the allowance for the personal needs of a waiver participant with a community spouse is different from
the amount used for the individual's maintenance allowance under 42 CFR §435.726 or 42 CFR §435.735,
explain why this amount is reasonable to meet the individual's maintenance needs in the community.
Select one:
Allowance is the same
Allowance is different.
Explanation of difference:
ii.
Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified
in 42 CFR §435.726:
Health insurance premiums, deductibles and co-insurance chargesa.
Necessary medical or remedial care expenses recognized under state law but not covered under the state's
Medicaid plan, subject to reasonable limits that the state may establish on the amounts of these expenses.
b.
iii.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 30 of 118
06/24/2020
Select one:
Not Applicable (see instructions)Note: If the state protects the maximum amount for the waiver participant,
not applicable must be selected.
The state does not establish reasonable limits.
The state uses the same reasonable limits as are used for regular (non-spousal) post-eligibility.
Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (5 of 7)
Note: The following selections apply for the five-year period beginning January 1, 2014.
Regular Post-Eligibility Treatment of Income: §1634 State - 2014 through 2018.
Answers provided in Appendix B-5-a indicate the selections in B-5-b also apply to B-5-e.
e.
Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (6 of 7)
Note: The following selections apply for the five-year period beginning January 1, 2014.
Regular Post-Eligibility Treatment of Income: 209(B) State - 2014 through 2018.
Answers provided in Appendix B-4 indicate that you do not need to complete this section and therefore this section
is not visible.
f.
Appendix B: Participant Access and Eligibility
B-5: Post-Eligibility Treatment of Income (7 of 7)
Note: The following selections apply for the five-year period beginning January 1, 2014.
Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules - 2014 through 2018.
The state uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the
contribution of a participant with a community spouse toward the cost of home and community-based care. There is
deducted from the participant's monthly income a personal needs allowance (as specified below), a community spouse's
allowance and a family allowance as specified in the state Medicaid Plan. The state must also protect amounts for incurred
expenses for medical or remedial care (as specified below).
Answers provided in Appendix B-5-a indicate the selections in B-5-d also apply to B-5-g.
g.
Appendix B: Participant Access and Eligibility
B-6: Evaluation/Reevaluation of Level of Care
As specified in 42 CFR §441.302(c), the state provides for an evaluation (and periodic reevaluations) of the need for the level(s)
of care specified for this waiver, when there is a reasonable indication that an individual may need such services in the near
future (one month or less), but for the availability of home and community-based waiver services.
Reasonable Indication of Need for Services. In order for an individual to be determined to need waiver services, an
individual must require: (a) the provision of at least one waiver service, as documented in the service plan, and (b) the
provision of waiver 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 service plan. Specify the state's policies concerning the
reasonable indication of the need for services:
Minimum number of services.
The minimum number of waiver services (one or more) that an individual must require in order to be determined to
i.
a.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 31 of 118
06/24/2020
need waiver services is:
1
Frequency of services. The state requires (select one):
The provision of waiver 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 waiver services other than monthly (e.g.,
quarterly), specify the frequency:
ii.
Responsibility for Performing Evaluations and Reevaluations. Level of care evaluations and reevaluations are
performed (select one):
Directly by the Medicaid agency
By the operating agency specified in Appendix A
By a government agency under contract with the Medicaid agency.
Specify the entity:
Other
Specify:
The Model Waiver level of care evaluations and reevaluations are performed through the DOH's CMS, specifically
by their Children's Multi-disicplinary Assessment Team (CMAT).
b.
Qualifications of Individuals Performing Initial Evaluation: Per 42 CFR §441.303(c)(1), specify the
educational/professional qualifications of individuals who perform the initial evaluation of level of care for waiver
applicants:
Initial evaluations will be completed by a medical physician (MD or DO), registered nurse (RN) or an advanced
registered nurse practitioner (ARNP).
A medical physician must be licensed as one of the following:
Medical physician (MD) within the scope of the practice of medicine as defined in Chapter 458, Florida Statutes;
Osteopathic physician (DO) within the scope of the practice of osteopathic medicine as defined in Chapter 459, Florida
Statutes; or
Medical or osteopathic physician licensed in the state in which the service is provided.
A registered nurse is an individual who is licensed to practice professional nursing in accordance with Chapter 464,
Florida Statutes.
An Advanced Registered Nurse Practitioner (ARNP) is a licensed advanced registered nurse practitioner who works in
collaboration with a physician according to protocol to provide diagnostic and interventional patient care. An Advanced
Registered Nurse Practitioner (ARNP) must be authorized to provide these services by Chapter 464, Florida Statutes, and
protocols filed with the Board of Medicine.
c.
Level of Care Criteria. Fully specify the level of care criteria that are used to evaluate and reevaluate whether an
individual needs services through the waiver and that serve as the basis of the state's level of care instrument/tool. Specify
the level of care instrument/tool that is employed. State laws, regulations, and policies concerning level of care criteria and
the level of care instrument/tool are available to CMS upon request through the Medicaid agency or the operating agency
(if applicable), including the instrument/tool utilized.
d.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 32 of 118
06/24/2020
The following level of care (LOC) criteria are used to evaluate and reevaluate whether an individual needs services
through the Model Waiver and is a component of the level of care instrument/tool.
Model Waiver recipients LOC criteria must meet the following:
1. "at risk of hospitalization" or skilled nursing facility by the CMAT
2. Able to live safely at home with the Medicaid Home and Community Based Services made available to the recipient.
Level of Care: The assessment interviews for waiver applicants are conducted by the CMAT team using the Level of
Care AHCA Form 5000-28. The completed assessment forms are reviewed by CMAT to determine the level of care for
waiver services. In order to qualify for the Model Waiver services, the applicant must qualify as "At Risk For
Hospitalization" or must meet skilled nursing facility level of care. The completed AHCA Form 5000-28 is sent to the
Medicaid Agency for review and approval.
Level of Care Instrument(s). Per 42 CFR §441.303(c)(2), indicate whether the instrument/tool used to evaluate level of
care for the waiver differs from the instrument/tool used to evaluate institutional level of care (select one):
The same instrument is used in determining the level of care for the waiver and for institutional care under the
state Plan.
A different instrument is used to determine the level of care for the waiver than for institutional care under the
state plan.
Describe how and why this instrument differs from the form used to evaluate institutional level of care and explain
how the outcome of the determination is reliable, valid, and fully comparable.
e.
Process for Level of Care Evaluation/Reevaluation: Per 42 CFR §441.303(c)(1), 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:
The assessment interviews for waiver applicants are conducted by Childrens Multi-disciplinary Assessment Team
(CMAT) program staff using the Level of Care AHCA Form 5000-28. The completed assessment forms are reviewed by
CMAT to determine level of care for waiver services. In order to qualify for the Model Waiver services the applicant
must qualify as at risk for hospitalization or must meet skilled nursing facility level of care and reside in a skilled nursing
facility for a minimum of 60 days. The completed AHCA Form 5000-28 is sent to the Model Waiver analyst for review
and approval.
After a recipient as been placed on the Model Waiver their level of care will be reevaulated annually by the same
instrument and process used for the inital Level of Care evaluation, the AHCA Form 5000-28. The completed form is
then sent to Medicaid Headquarter Model Waiver analyst for notificaiton that the recipient continues to meet level of care
at risk for hospitalization or skilled nursing facility level of care in order to remain on the Model Waiver.
f.
Reevaluation Schedule. Per 42 CFR §441.303(c)(4), reevaluations of the level of care required by a participant are
conducted no less frequently than annually according to the following schedule (select one):
Every three months
Every six months
Every twelve months
Other schedule
Specify the other schedule:
g.
Qualifications of Individuals Who Perform Reevaluations. Specify the qualifications of individuals who perform
reevaluations (select one):
h.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 33 of 118
06/24/2020
The qualifications of individuals who perform reevaluations are the same as individuals who perform initial
evaluations.
The qualifications are different.
Specify the qualifications:
Procedures to Ensure Timely Reevaluations. Per 42 CFR §441.303(c)(4), specify the procedures that the state employs
to ensure timely reevaluations of level of care (specify):
The waiver recipients' care coordinator, through CMS will track the due date for reevaluation as a part of their case
management responsibilities. The care coordinator will initiate activity to obtain the referral form from the reciepients'
physician and will complete all other necessary requirements with sufficient time to complete a referral to the CMAT by
the date which will permit a timely reevaluation.
i.
Maintenance of Evaluation/Reevaluation Records. Per 42 CFR §441.303(c)(3), the state assures that written and/or
electronically retrievable documentation of all evaluations and reevaluations are maintained for a minimum period of 3
years as required in 45 CFR §92.42. Specify the location(s) where records of evaluations and reevaluations of level of care
are maintained:
1. The care coordinator is responsible for developing and maintaining a central case record for every Model Waiver
recipient. The purpose of this central record is to assure that information reqarding the recipient's condition and service
provision is contained in a single location to promote continuity and quality of care. It is the basis for quality assurance
monitoring.
2. The area Medicaid office must keep a working file of each Model Waiver recipient receiving services in their area.
This working file will include current copies of each reciepients Level of Care (LOC) evaluations and Plan of Care
(POC). They will then send a copy of the updated records to the AHCA Model Waiver analyst.
3. The Model Waiver analyst at the Medicaid Agency will also receive copies of evaluations and reevaluations of LOC
and POC from the area office contact.
j.
Appendix B: Evaluation/Reevaluation of Level of Care
Quality Improvement: Level of Care
As a distinct component of the States quality improvement strategy, provide information in the following fields to detail the States
methods for discovery and remediation.
Methods for Discovery: Level of Care Assurance/Sub-assurances
The state demonstrates that it implements the processes and instrument(s) specified in its approved waiver for
evaluating/reevaluating an applicant's/waiver participant's level of care consistent with level of care provided in a
hospital, NF or ICF/IID.
Sub-Assurances:
Sub-assurance: An evaluation for LOC is provided to all applicants for whom there is reasonable
indication that services may be needed in the future.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or
sub-assurance), complete the following. Where possible, include numerator/denominator.
a.
i.
a.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 34 of 118
06/24/2020
For each performance measure, provide information on the aggregated data that will enable the State to
analyze and assess progress toward the performance measure. In this section provide information on the
method by which each source of data is analyzed statistically/deductively or inductively, how themes are
identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Percentage of applicants receiving a level of care determination prior to enrollment.
Numerator: Number of applicants receiving a level of care determination prior to
enrollment. Denominator: Number of applicants.
Data Source (Select one):
Record reviews, on-site
If 'Other' is selected, specify:
Responsible Party for
data
collection/generation
(check each that applies):
Frequency of data
collection/generation
(check each that applies):
Sampling Approach
(check each that applies):
State Medicaid
Agency
Weekly 100% Review
Operating Agency Monthly Less than 100%
Review
Sub-State Entity Quarterly Representative
Sample
Confidence
Interval =
Other
Specify:
Annually Stratified
Describe Group:
Continuously and
Ongoing
Other
Specify:
Other
Specify:
Data Aggregation and Analysis:
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 35 of 118
06/24/2020
Responsible Party for data
aggregation and analysis (check each
that applies):
Frequency of data aggregation and
analysis(check each that applies):
State Medicaid Agency Weekly
Operating Agency Monthly
Sub-State Entity Quarterly
Other
Specify:
Annually
Continuously and Ongoing
Other
Specify:
Sub-assurance: The levels of care of enrolled participants are reevaluated at least annually or as
specified in the approved waiver.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or
sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to
analyze and assess progress toward the performance measure. In this section provide information on the
method by which each source of data is analyzed statistically/deductively or inductively, how themes are
identified or conclusions drawn, and how recommendations are formulated, where appropriate.
b.
Sub-assurance: The processes and instruments described in the approved waiver are applied
appropriately and according to the approved description to determine participant level of care.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or
sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to
analyze and assess progress toward the performance measure. In this section provide information on the
method by which each source of data is analyzed statistically/deductively or inductively, how themes are
identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Percentage of initial level of care determinations that are accurately completed in
c.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 36 of 118
06/24/2020
accordance with State policies and procedures. Numerator: Number of initial level of
care determinations that were accurately completed in accordance with State policies
and procedures. Denominator: Number of initial level of care determinations.
Data Source (Select one):
Record reviews, on-site
If 'Other' is selected, specify:
Responsible Party for
data
collection/generation
(check each that applies):
Frequency of data
collection/generation
(check each that applies):
Sampling Approach
(check each that applies):
State Medicaid
Agency
Weekly 100% Review
Operating Agency Monthly Less than 100%
Review
Sub-State Entity Quarterly Representative
Sample
Confidence
Interval =
Other
Specify:
Annually Stratified
Describe Group:
Continuously and
Ongoing
Other
Specify:
Other
Specify:
Data Aggregation and Analysis:
Responsible Party for data
aggregation and analysis (check each
that applies):
Frequency of data aggregation and
analysis(check each that applies):
State Medicaid Agency Weekly
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 37 of 118
06/24/2020
Responsible Party for data
aggregation and analysis (check each
that applies):
Frequency of data aggregation and
analysis(check each that applies):
Operating Agency Monthly
Sub-State Entity Quarterly
Other
Specify:
Annually
Continuously and Ongoing
Other
Specify:
If applicable, in the textbox below provide any necessary additional information on the strategies employed by the
State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
ii.
Methods for Remediation/Fixing Individual Problems
Describe the States method for addressing individual problems as they are discovered. Include information
regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on
the methods used by the state to document these items.
The recipient's CMAT Nurse and eQ Health Care Coordinator will participate in the LOC staffing. The CMAT
Nurse serves as an advocate on behalf of the recipient to ensure that the LOC determination process was
appropriate in assessing the recipient's risk level. The eQ Health Care Coordinator serves as an advocate for the
recipient in making sure that he or she receives the services that are necessary. In addition, the recipient is
informed of their right to request a fair hearing under the authority of 42 CFR Part 431, Subpart E, if they are not
satisfied with the LOC determination process.
i.
Remediation Data Aggregation
Remediation-related Data Aggregation and Analysis (including trend identification)
Responsible Party(check each that applies):
Frequency of data aggregation and analysis
(check each that applies):
State Medicaid Agency Weekly
Operating Agency Monthly
Sub-State Entity Quarterly
Other
Specify:
Annually
ii.
b.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 38 of 118
06/24/2020
Responsible Party(check each that applies):
Frequency of data aggregation and analysis
(check each that applies):
Continuously and Ongoing
Other
Specify:
Timelines
When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design
methods for discovery and remediation related to the assurance of Level of Care that are currently non-operational.
No
Yes
Please provide a detailed strategy for assuring Level of Care, the specific timeline for implementing identified
strategies, and the parties responsible for its operation.
c.
Appendix B: Participant Access and Eligibility
B-7: Freedom of Choice
Freedom of Choice. As provided in 42 CFR §441.302(d), when an individual is determined to be likely to require a level of care
for this waiver, the individual or his or her legal representative is:
informed of any feasible alternatives under the waiver; andi.
given the choice of either institutional or home and community-based services.ii.
Procedures. Specify the state's procedures for informing eligible individuals (or their legal representatives) of the feasible
alternatives available under the waiver and allowing these individuals to choose either institutional or waiver services.
Identify the form(s) that are employed to document freedom of choice. The form or forms are available to CMS upon
request through the Medicaid agency or the operating agency (if applicable).
a.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 39 of 118
06/24/2020
All waiver recipients receive information from their care coordinator who provides comprehensive information detailing
the medical services package available to the participant in the home and community. The recipient is given the choice to
receive services in the waiver or receive services in an institutional setting.
As part of the MW enrollment process the AHCA Form 5000-26 is read/explained and given to the participant and family
to sign and date, if they chose to particiapte in this waiver.
MODEL WAIVER
PARTICIPANT RIGHTS AND RESPONSIBILITIES
Your child has been determined eligible to receive home and community based services under the Model Waiver
program. Under this program you have certain rights and responsibilities on behalf of your child. These include:
I. Freedom of Choice
You have the right to choose care for your child through this Model Waiver program or admission to a hospital. You have
the right to choose care for your child through the Model Waiver program or receive care from a skilled nursing facility.
You have the right to choose the service providers from whom your child will receive Model Waiver services.
You have the right to choose any care coordinator to the extent they are available and have chosen to participate in this
program.
II. Right of Appeal
If your child is denied a service you believe he or she is eligible to receive, you have the right to appeal the decision.
Pursuant to 42 CFR, Part 431, subpart E, the decision may be appealed by requesting a Fair Hearing by a State Hearings
Office with the DCF.
III. Responsibilities
You are responsible for assisting your care coordinator in developing your childs Plan of Care and schedule of services.
You are responsible for notifying your care coordinator when you have problems in obtaining services or when you are
dissatisfied with the care.
You are responsible for following health care instructions to the best of your ability.
I certify that I have received and reviewed a copy of this Model Waiver, Participant Rights and Responsibilities. I agree
to abide by and adhere to the responsibilities listed above.
Parent/Legal Guardian Signature Date
AHCA Form 5000-26
Maintenance of Forms. Per 45 CFR §92.42, written copies or electronically retrievable facsimiles of Freedom of Choice
forms are maintained for a minimum of three years. Specify the locations where copies of these forms are maintained.
Copies of forms documenting freedom of choice will be maintained by care coordinators, and the Medicaid Agency.
b.
Appendix B: Participant Access and Eligibility
B-8: Access to Services by Limited English Proficiency Persons
Access to Services by Limited English Proficient Persons. Specify the methods that the state uses to provide meaningful access
to the waiver by Limited English Proficient persons in accordance with the Department of Health and Human Services "Guidance
to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting
Limited English Proficient Persons" (68 FR 47311 - August 8, 2003):
Waiver access to Limited English Proficient individuals will be provided through interpreters. Documents and communications
that are translated in to the primary language of the recipient will also be used. In absence of CMS staff who are proficient in the
language of the applicant, translators will be located through established registries maintained by other state and government
agencies or through local educational intstitutions.
Appendix C: Participant Services
C-1: Summary of Services Covered (1 of 2)
Waiver Services Summary. List the services that are furnished under the waiver in the following table. If case
management is not a service under the waiver, complete items C-1-b and C-1-c:
a.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 40 of 118
06/24/2020
Service Type Service
Statutory Service Respite
Extended State Plan Service Transition Case Management
Other Service Environmental Accessiblity Adaptations
Appendix C: Participant Services
C-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through
the Medicaid agency or the operating agency (if applicable).
Service Type:
Statutory Service
Service:
Respite
Alternate Service Title (if any):
HCBS Taxonomy:
Complete this part for a renewal application or a new waiver that replaces an existing waiver. Select one :
Service is included in approved waiver. There is no change in service specifications.
Service is included in approved waiver. The service specifications have been modified.
Service is not included in the approved waiver.
Service Definition (Scope):
Category 1:
Sub-Category 1:
Category 2:
Sub-Category 2:
Category 3:
Sub-Category 3:
Category 4:
Sub-Category 4:
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 41 of 118
06/24/2020
Respite care services are provided on a short-term basis as a temporary support to the recipient's family. It may be
provided in the absence of or for relief of the recipients family. Respite care may be used to meet a range of recipient
needs. These include:
1. Family emergencies;
2. Planned absences, such as vacations, hospitalizations or business trips;
3. Relief from the stresses of caregiving; and
4. Giving the child respite from his family.
Respite care may be provided in the recipient's home, place of residence or a Medicaid certified hospital.
Specify applicable (if any) limits on the amount, frequency, or duration of this service:
Respite care service providers are not reimbursed separately for transportation and travel cost. These costs are
integral components of respite care services, and are included in the basic fee.
Respite care services that have been determined medically necessary are limited to the amount, duration, and scope
of the service described on the recipients support plan and current approved cost plan to foster health, safety, and
welfare of the recipient. Provider reimbursement guidelines are set by the Agency for Health Care Administration
with input from CMS, these guidelines are incorporated by reference in Rule 59G-13.083 Florida Administrative
Code. 1 unit is equal to 15 minutes and cost $8.00 per unit. Total units of respite services allowed through the Model
Waiver is 970. Total units of service are based on a state fiscal year. Respite care services can be used to provide
temporary relief to primary caregivers when this function cannot be accommodated by other providers (e.g.
homemaker, home health aide, companion, day care, etc.) in conjunction with their assigned responsibilities. Respite
care services can be provided on a 24-hour basis, but are limited to a total of ten (10) 24-hour days per calendar year.
Service Delivery Method (check each that applies):
Participant-directed as specified in Appendix E
Provider managed
Specify whether the service may be provided by (check each that applies):
Legally Responsible Person
Relative
Legal Guardian
Provider Specifications:
Provider Category Provider Type Title
Agency Hospital
Agency Home Health Agency
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Statutory Service
Service Name: Respite
Provider Category:
Agency
Provider Type:
Hospital
Provider Qualifications
License (specify):
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 42 of 118
06/24/2020
Licensed under Chapter 400, Part II, Florida Statutes.
Certificate (specify):
Other Standard (specify):
Verification of Provider Qualifications
Entity Responsible for Verification:
Model Waiver analyst, verifies provider qualifications prior to the issuance of a provider referral
agreement to provide services under the Model Waiver.
Frequency of Verification:
Provider qualifications are examined for compliance annually by the Model Waiver analyst.
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Statutory Service
Service Name: Respite
Provider Category:
Agency
Provider Type:
Home Health Agency
Provider Qualifications
License (specify):
Providers of respite care must be a home health agency licensed in accordance with Chapter 400, F.S.,
and Chapter 59A-8, Florida Administrative Code (F.A.C.) and meeting Federal Conditions of
Participation under 42 C.F.R. 84.
Certificate (specify):
Other Standard (specify):
Medicaid Model Waiver providers must:
1. Be enrollement with the Medicaid fiscal agent as a Model Waiver provders, and
2. Not be currently suspended from Medicare or Mediciad in any state.
Verification of Provider Qualifications
Entity Responsible for Verification:
Agency for Health Care Administration
Frequency of Verification:
Upon enrollment
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 43 of 118
06/24/2020
Appendix C: Participant Services
C-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through
the Medicaid agency or the operating agency (if applicable).
Service Type:
Extended State Plan Service
Service Title:
Transition Case Management
HCBS Taxonomy:
Complete this part for a renewal application or a new waiver that replaces an existing waiver. Select one :
Service is included in approved waiver. There is no change in service specifications.
Service is included in approved waiver. The service specifications have been modified.
Service is not included in the approved waiver.
Service Definition (Scope):
Transition Case Management services are specialized case management services provided to Medicaid waiver
eligible recipients who currently reside in a nursing home and wish to transition to a less restrictive and more
integrated environment within the community. Nursing home transition case managers will work with an individual
residing in a nursing home to facilitate that individual’s return to a safe and appropriate community setting. Case
managers will include the individual’s caregivers or legal representatives in the planning for transition.
Specify applicable (if any) limits on the amount, frequency, or duration of this service:
There are no limits for this medically necessary service all candidates are 0 to 20 years of age.
Transition case management may be furnished as a waiver service to Medicaid eligible individuals residing in
nursing facilities for up 180 consecutive days (six months) prior to discharge from the nursing facility. The case
management entity is not authorized to bill for the service provided until after the individual is discharged from the
nursing facility and enrolled as a waiver participant.
Service Delivery Method (check each that applies):
Participant-directed as specified in Appendix E
Category 1:
Sub-Category 1:
Category 2:
Sub-Category 2:
Category 3:
Sub-Category 3:
Category 4:
Sub-Category 4:
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 44 of 118
06/24/2020
Provider managed
Specify whether the service may be provided by (check each that applies):
Legally Responsible Person
Relative
Legal Guardian
Provider Specifications:
Provider Category Provider Type Title
Individual Transition Case Manager
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Extended State Plan Service
Service Name: Transition Case Management
Provider Category:
Individual
Provider Type:
Transition Case Manager
Provider Qualifications
License (specify):
Certificate (specify):
Other Standard (specify):
Master’s or Bachelor’s degree from an accredited university or college with a major in nursing,
rehabilitation counseling, social work, psychology, or a related social services field or rehabilitative
science or education and three years professional experience in a rehabilitative program. All providers
must demonstrate a working knowledge of the medically fragile, technologically dependant, and
physical complex population. Documentation of coursework, experience or training which illustrates this
must be submitted.
Verification of Provider Qualifications
Entity Responsible for Verification:
The Provider Enrollment Specialist at the local Medicaid area office will review and verify that provider
qualifications are met.
Frequency of Verification:
All provider qualifications will be examined on an annual basis.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 45 of 118
06/24/2020
Appendix C: Participant Services
C-1/C-3: Service Specification
State laws, regulations and policies referenced in the specification are readily available to CMS upon request through
the Medicaid agency or the operating agency (if applicable).
Service Type:
Other Service
As provided in 42 CFR §440.180(b)(9), the State requests the authority to provide the following additional service not
specified in statute.
Service Title:
Environmental Accessiblity Adaptations
HCBS Taxonomy:
Complete this part for a renewal application or a new waiver that replaces an existing waiver. Select one :
Service is included in approved waiver. There is no change in service specifications.
Service is included in approved waiver. The service specifications have been modified.
Service is not included in the approved waiver.
Service Definition (Scope):
Category 1:
Sub-Category 1:
Category 2:
Sub-Category 2:
Category 3:
Sub-Category 3:
Category 4:
Sub-Category 4:
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 46 of 118
06/24/2020
Environmental accessibility adaptations are physical modifications to the recipients home that:
Are necessary to ensure the health, welfare and safety of the recipient, or enable the recipient to function with
greater independence in the home; and if not completed, the recipient would require institutionalization.
The following are examples of modifications reimbursed through the Model Waiver:
Installation of ramps and grab-bars;
Widening of doorways,
Changes to bathroom facilities; and
Installation of specialized electric and plumbing systems necessary to accommodate required medical equipment and
supplies.
All modification services must be provided in accordance with applicable state and local building codes.
Excluded Modifications:
Those adaptations or improvements to the home that are general utility and not of direct medical or remedial benefit
to the recipient are not reimbursed through the Modal Waiver.
Examples of excluded modifications are:
Carpeting;
Roof repair;
Central air conditioning; or
Changes that add to the total square footage of the home.
Specify applicable (if any) limits on the amount, frequency, or duration of this service:
Service Requirements:
This service will only be reimbursed based on certification through an assistive technology service evaluation
that such modifications are necessary to prevent institutionalization.
One occurrence per year and cannot exceed $5,000.00
Service Limitations:
Environmental accessibility adaptation services are limited to the
amount, duration and scope of services described in the recipients plan of care.
Service Delivery Method (check each that applies):
Participant-directed as specified in Appendix E
Provider managed
Specify whether the service may be provided by (check each that applies):
Legally Responsible Person
Relative
Legal Guardian
Provider Specifications:
Provider Category Provider Type Title
Agency Environmental Accessibility Adaptions
Appendix C: Participant Services
C-1/C-3: Provider Specifications for Service
Service Type: Other Service
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 47 of 118
06/24/2020
Service Name: Environmental Accessiblity Adaptations
Provider Category:
Agency
Provider Type:
Environmental Accessibility Adaptions
Provider Qualifications
License (specify):
Department of Business and Professional Regulations (DBPR) in accordance with Chapter 489, F.S.
Certificate (specify):
Other Standard (specify):
Model Waiver Provider Qualifications
Medicaid Model Waiver providers must:
Be enrolled with the Medicaid fiscal agent as a Model Waiver provider, and
Not be currently suspended from Medicare or Medicaid in any state.
Providers who furnish environmental accessibility adaptations must be contractors licensed by the
Department of Business and Professional Regulations (DBPR) in accordance with Chapter 489, F.S.
Verification of Provider Qualifications
Entity Responsible for Verification:
Agency for Health Care Administration
Frequency of Verification:
Upon Enrollment
Appendix C: Participant Services
C-1: Summary of Services Covered (2 of 2)
Provision of Case Management Services to Waiver Participants. Indicate how case management is furnished to waiver
participants (select one):
Not applicable - Case management is not furnished as a distinct activity to waiver participants.
Applicable - Case management is furnished as a distinct activity to waiver participants.
Check each that applies:
As a waiver service defined in Appendix C-3. Do not complete item C-1-c.
As a Medicaid state plan service under §1915(i) of the Act (HCBS as a State Plan Option). Complete item
C-1-c.
As a Medicaid state plan service under §1915(g)(1) of the Act (Targeted Case Management). Complete item
C-1-c.
As an administrative activity. Complete item C-1-c.
b.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 48 of 118
06/24/2020
As a primary care case management system service under a concurrent managed care authority. Complete
item C-1-c.
Delivery of Case Management Services. Specify the entity or entities that conduct case management functions on behalf
of waiver participants:
A care coordinator is assigned to each Model Waiver recipient to ensure continuity of care and that the recipient and their
family are receiving all necessary support and services available through the waiver. Each participant will have a
multidisciplinary staffing which includes both the care coordinator and the CMAT nurse to aid in establishing the best
approach to meet their needs.
c.
Appendix C: Participant Services
C-2: General Service Specifications (1 of 3)
Criminal History and/or Background Investigations. Specify the state's policies concerning the conduct of criminal
history and/or background investigations of individuals who provide waiver services (select one):
No. Criminal history and/or background investigations are not required.
Yes. Criminal history and/or background investigations are required.
Specify: (a) the types of positions (e.g., personal assistants, attendants) for which such investigations must be
conducted; (b) the scope of such investigations (e.g., state, national); and, (c) the process for ensuring that mandatory
investigations have been conducted. State laws, regulations and policies referenced in this description are available to
CMS upon request through the Medicaid or the operating agency (if applicable):
a.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 49 of 118
06/24/2020
Chapter 435, Florida Statutes, states all employees or employers required by law to be screened shall undergo
background screenings. Florida Medicaid requires screening of all providers and provider employees according to
type of service provided. The screening requirements listed below apply to health care facilities or provider types
which are licensed by the Agency for Health Care Administration (AHCA) and included as providers under this
waiver program: Model Waiver. These provider types are subject to screening as required by Florida Statutes:
Direct Care Staff - Level I Criminal History Screening
Owner/Administrator - Level II Criminal History Screening
Financial Officer - Level II Criminal History Screening
Level I Screening Standards:
-Level I Criminal History - consists of a query of the Florida Department of Law Enforcement (FDLE) database for
the criminal arrest history of an individual.
-This screening shall include, but is not limited to: employment history checks; statewide criminal correspondence
checks; and may include local criminal records checks through local law enforcement agencies.
Level II Screening Standards:
-Level II Criminal History - consists of a search of the FDLE and the Federal Bureau of Investigations (FBI)
databases for any criminal arrest information both state and nationally.
-This screening shall include, but is not limited to: fingerprinting for all purposes; statewide criminal and juvenile
records checks; federal criminal records checks; and may include local criminal records checks through local law
enforcement agencies.
(c) All provider referral agreements are inspected prior to enrollment and then monitored annually by the Model
Waiver analyst. This process verifies the provider background screenings and provider qualifications prior to
renewal of the referral agreement for services.
In reference to facilities, to ensure that all background screening requirements have been met, interpretive guidelines
for annual licensure surveys require state surveyors to conduct personnel record reviews to verify that facilities have
evidence of required screening. As part of AHCA monitoring activities, each site's personnel records for their
subcontracted service providers are sampled for review to verify compliance with background screening
requirements.
Abuse Registry Screening. Specify whether the state requires the screening of individuals who provide waiver services
through a state-maintained abuse registry (select one):
No. The state does not conduct abuse registry screening.
Yes. The state maintains an abuse registry and requires the screening of individuals through this
registry.
Specify: (a) the entity (entities) responsible for maintaining the abuse registry; (b) the types of positions for which
abuse registry screenings must be conducted; and, (c) the process for ensuring that mandatory screenings have been
conducted. State laws, regulations and policies referenced in this description are available to CMS upon request
through the Medicaid agency or the operating agency (if applicable):
b.
Appendix C: Participant Services
C-2: General Service Specifications (2 of 3)
Services in Facilities Subject to §1616(e) of the Social Security Act. Select one:c.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 50 of 118
06/24/2020
No. Home and community-based services under this waiver are not provided in facilities subject to
§1616(e) of the Act.
Yes. Home and community-based services are provided in facilities subject to §1616(e) of the Act. The
standards that apply to each type of facility where waiver services are provided are available to CMS
upon request through the Medicaid agency or the operating agency (if applicable).
Appendix C: Participant Services
C-2: General Service Specifications (3 of 3)
Provision of Personal Care or Similar Services by Legally Responsible Individuals. A legally responsible individual is
any person who has a duty under state law to care for another person and typically includes: (a) the parent (biological or
adoptive) of a minor child or the guardian of a minor child who must provide care to the child or (b) a spouse of a waiver
participant. Except at the option of the State and under extraordinary circumstances specified by the state, payment may
not be made to a legally responsible individual for the provision of personal care or similar services that the legally
responsible individual would ordinarily perform or be responsible to perform on behalf of a waiver participant. Select one:
No. The state does not make payment to legally responsible individuals for furnishing personal care or similar
services.
Yes. The state makes payment to legally responsible individuals for furnishing personal care or similar services
when they are qualified to provide the services.
Specify: (a) the legally responsible individuals who may be paid to furnish such services and the services they may
provide; (b) state policies that specify the circumstances when payment may be authorized for the provision of
extraordinary care by a legally responsible individual and how the state ensures that the provision of services by a
legally responsible individual is in the best interest of the participant; and, (c) the controls that are employed to ensure
that payments are made only for services rendered. Also, specify in Appendix C-1/C-3 the personal care or similar
services for which payment may be made to legally responsible individuals under the state policies specified here.
d.
Self-directed
Agency-operated
Other State Policies Concerning Payment for Waiver Services Furnished by Relatives/Legal Guardians. Specify
state policies concerning making payment to relatives/legal guardians for the provision of waiver services over and above
the policies addressed in Item C-2-d. Select one:
The state does not make payment to relatives/legal guardians for furnishing waiver services.
The state makes payment to relatives/legal guardians under specific circumstances and only when the
relative/guardian is qualified to furnish services.
Specify the specific circumstances under which payment is made, the types of relatives/legal guardians to whom
payment may be made, and the services for which payment may be made. Specify the controls that are employed to
ensure that payments are made only for services rendered. Also, specify in Appendix C-1/C-3 each waiver service for
which payment may be made to relatives/legal guardians.
Relatives/legal guardians may be paid for providing waiver services whenever the relative/legal guardian is
qualified to provide services as specified in Appendix C-1/C-3.
e.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 51 of 118
06/24/2020
Specify the controls that are employed to ensure that payments are made only for services rendered.
Other policy.
Specify:
Open Enrollment of Providers. Specify the processes that are employed to assure that all willing and qualified providers
have the opportunity to enroll as waiver service providers as provided in 42 CFR §431.51:
The Medicaid Agency works with the APD to solicit current Home and Community-Based Services Waiver providers in
good standing to provide services to the Model Waiver population. Interested providers must submit a request to the
Medicaid Agency to add a designated specialty code to their Medicaid provider number in order to bill for their services.
The Medicaid Agency accepts applications for new Model waiver providers on a continuous basis.
All willing and qualified providers have the opportunity to apply to be a Model waiver service provider. The State
Medicaid Agency has a provider enrollment unit to assist interested providers in the enrollment process. An online
application as well as the phone number for provider enrollment is posted on the Florida Medicaid Web Portal.
f.
Appendix C: Participant Services
Quality Improvement: Qualified Providers
As a distinct component of the States quality improvement strategy, provide information in the following fields to detail the States
methods for discovery and remediation.
Methods for Discovery: Qualified Providers
The state demonstrates that it has designed and implemented an adequate system for assuring that all waiver services
are provided by qualified providers.
Sub-Assurances:
Sub-Assurance: 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.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance,
complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to
analyze and assess progress toward the performance measure. In this section provide information on the
method by which each source of data is analyzed statistically/deductively or inductively, how themes are
identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Percentage of new licensed providers satisfying waiver service provider qualifications
prior to delivering services. Numerator: Number of new licensed providers satisfying
a.
i.
a.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 52 of 118
06/24/2020
waiver service provider qualification Denominator: Number of new licensed
providers
Data Source (Select one):
Record reviews, on-site
If 'Other' is selected, specify:
Responsible Party for
data
collection/generation
(check each that applies):
Frequency of data
collection/generation
(check each that applies):
Sampling Approach
(check each that applies):
State Medicaid
Agency
Weekly 100% Review
Operating Agency Monthly Less than 100%
Review
Sub-State Entity Quarterly Representative
Sample
Confidence
Interval =
Other
Specify:
Annually Stratified
Describe Group:
Continuously and
Ongoing
Other
Specify:
Other
Specify:
Data Aggregation and Analysis:
Responsible Party for data
aggregation and analysis (check each
that applies):
Frequency of data aggregation and
analysis(check each that applies):
State Medicaid Agency Weekly
Operating Agency Monthly
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 53 of 118
06/24/2020
Responsible Party for data
aggregation and analysis (check each
that applies):
Frequency of data aggregation and
analysis(check each that applies):
Sub-State Entity Quarterly
Other
Specify:
Annually
Continuously and Ongoing
Other
Specify:
Performance Measure:
Percentage of Model waiver providers continuously qualified on an annual basis.
Numerator: Number of Model Waiver providers continuously qualified on an annual
basis Denominator: Number of providers enrolled as Model Waiver providers
Data Source (Select one):
Record reviews, on-site
If 'Other' is selected, specify:
Responsible Party for
data
collection/generation
(check each that applies):
Frequency of data
collection/generation
(check each that applies):
Sampling Approach
(check each that applies):
State Medicaid
Agency
Weekly 100% Review
Operating Agency Monthly Less than 100%
Review
Sub-State Entity Quarterly Representative
Sample
Confidence
Interval =
Other
Specify:
Annually Stratified
Describe Group:
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 54 of 118
06/24/2020
Continuously and
Ongoing
Other
Specify:
Other
Specify:
Data Aggregation and Analysis:
Responsible Party for data
aggregation and analysis (check each
that applies):
Frequency of data aggregation and
analysis(check each that applies):
State Medicaid Agency Weekly
Operating Agency Monthly
Sub-State Entity Quarterly
Other
Specify:
Annually
Continuously and Ongoing
Other
Specify:
Sub-Assurance: The State monitors non-licensed/non-certified providers to assure adherence to waiver
requirements.
For each performance measure the State will use to assess compliance with the statutory assurance,
complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to
analyze and assess progress toward the performance measure. In this section provide information on the
method by which each source of data is analyzed statistically/deductively or inductively, how themes are
identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
b.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 55 of 118
06/24/2020
Percentage of new non-licensed/non-certified providers satisfying waiver services
provider qualifications prior to delivery of services Numerator: Number of non-
licensed/non-certified providers that meet provider qualifications prior to delivery of
services Denominator: Number of new non-licensed/non-certified Waiver providers
Data Source (Select one):
Record reviews, on-site
If 'Other' is selected, specify:
Responsible Party for
data
collection/generation
(check each that applies):
Frequency of data
collection/generation
(check each that applies):
Sampling Approach
(check each that applies):
State Medicaid
Agency
Weekly 100% Review
Operating Agency Monthly Less than 100%
Review
Sub-State Entity Quarterly Representative
Sample
Confidence
Interval =
Other
Specify:
Annually Stratified
Describe Group:
Continuously and
Ongoing
Other
Specify:
Other
Specify:
Data Aggregation and Analysis:
Responsible Party for data
aggregation and analysis (check each
that applies):
Frequency of data aggregation and
analysis(check each that applies):
State Medicaid Agency Weekly
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 56 of 118
06/24/2020
Responsible Party for data
aggregation and analysis (check each
that applies):
Frequency of data aggregation and
analysis(check each that applies):
Operating Agency Monthly
Sub-State Entity Quarterly
Other
Specify:
Annually
Continuously and Ongoing
Other
Specify:
Sub-Assurance: The State implements its policies and procedures for verifying that provider training is
conducted in accordance with state requirements and the approved waiver.
For each performance measure the State will use to assess compliance with the statutory assurance,
complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to
analyze and assess progress toward the performance measure. In this section provide information on the
method by which each source of data is analyzed statistically/deductively or inductively, how themes are
identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Percentage of providers with staff mandated to report abuse, neglect, and
exploitation, which have received the appropriate training Numerator: Number of
providers with staff mandated to report abuse, neglect, and exploitation which have
received the appropriate training Denominator: Number of providers with staff who
are mandated reporters
Data Source (Select one):
Record reviews, on-site
If 'Other' is selected, specify:
Responsible Party for
data
collection/generation
(check each that applies):
Frequency of data
collection/generation
(check each that applies):
Sampling Approach
(check each that applies):
State Medicaid
Agency
Weekly 100% Review
Less than 100% Operating Agency Monthly
c.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 57 of 118
06/24/2020
Review
Sub-State Entity Quarterly Representative
Sample
Confidence
Interval =
Other
Specify:
Annually Stratified
Describe Group:
Continuously and
Ongoing
Other
Specify:
Other
Specify:
Data Aggregation and Analysis:
Responsible Party for data
aggregation and analysis (check each
that applies):
Frequency of data aggregation and
analysis(check each that applies):
State Medicaid Agency Weekly
Operating Agency Monthly
Sub-State Entity Quarterly
Other
Specify:
Annually
Continuously and Ongoing
Other
Specify:
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 58 of 118
06/24/2020
Responsible Party for data
aggregation and analysis (check each
that applies):
Frequency of data aggregation and
analysis(check each that applies):
If applicable, in the textbox below provide any necessary additional information on the strategies employed by the
State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
ii.
Methods for Remediation/Fixing Individual Problems
Describe the States method for addressing individual problems as they are discovered. Include information
regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on
the methods used by the state to document these items.
Providers are required to remediate all deficiencies. The Medicaid Agency works with providers on a one-to-one
basis to facilitate problem resolution to completion.
Providers who do not continually meet required training, license, certification, or other standards will be notified
by the Medicaid Agency in writing of non-compliance.
If the appropriate credentials are not provided within 30 days, the provider will be disenrolled and any claims
billed will be subject to recoupment.
i.
Remediation Data Aggregation
Remediation-related Data Aggregation and Analysis (including trend identification)
Responsible Party(check each that applies):
Frequency of data aggregation and analysis
(check each that applies):
State Medicaid Agency Weekly
Operating Agency Monthly
Sub-State Entity Quarterly
Other
Specify:
Annually
Continuously and Ongoing
Other
Specify:
ii.
b.
Timelines
When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design
methods for discovery and remediation related to the assurance of Qualified Providers that are currently non-operational.
c.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 59 of 118
06/24/2020
No
Yes
Please provide a detailed strategy for assuring Qualified Providers, the specific timeline for implementing identified
strategies, and the parties responsible for its operation.
Appendix C: Participant Services
C-3: Waiver Services Specifications
Section C-3 'Service Specifications' is incorporated into Section C-1 'Waiver Services.'
Appendix C: Participant Services
C-4: Additional Limits on Amount of Waiver Services
Additional Limits on Amount of Waiver Services. Indicate whether the waiver employs any of the following additional
limits on the amount of waiver services (select one).
Not applicable- The state does not impose a limit on the amount of waiver services except as provided in Appendix
C-3.
Applicable - The state imposes additional limits on the amount of waiver services.
When a limit is employed, specify: (a) the waiver services to which the limit applies; (b) the basis of the limit,
including its basis in historical expenditure/utilization patterns and, as applicable, the processes and methodologies
that are used to determine the amount of the limit to which a participant's services are subject; (c) how the limit will
be adjusted over the course of the waiver period; (d) provisions for adjusting or making exceptions to the limit based
on participant health and welfare needs or other factors specified by the state; (e) the safeguards that are in effect
when the amount of the limit is insufficient to meet a participant's needs; (f) how participants are notified of the
amount of the limit. (check each that applies)
Limit(s) on Set(s) of Services. There is a limit on the maximum dollar amount of waiver services that is
authorized for one or more sets of services offered under the waiver.
Furnish the information specified above.
Prospective Individual Budget Amount. There is a limit on the maximum dollar amount of waiver services
authorized for each specific participant.
Furnish the information specified above.
Budget Limits by Level of Support. Based on an assessment process and/or other factors, participants are
assigned to funding levels that are limits on the maximum dollar amount of waiver services.
Furnish the information specified above.
Other Type of Limit. The state employs another type of limit.
a.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 60 of 118
06/24/2020
Describe the limit and furnish the information specified above.
Appendix C: Participant Services
C-5: Home and Community-Based Settings
Explain how residential and non-residential settings in this waiver comply with federal HCB Settings requirements at 42 CFR
441.301(c)(4)-(5) and associated CMS guidance. Include:
Description of the settings and how they meet federal HCB Settings requirements, at the time of submission and in the
future.
1.
Description of the means by which the state Medicaid agency ascertains that all waiver settings meet federal HCB Setting
requirements, at the time of this submission and ongoing.
2.
Note instructions at Module 1, Attachment #2, HCB Settings Waiver Transition Plan for description of settings that do not meet
requirements at the time of submission. Do not duplicate that information here.
This waiver does not have any provider operated or controlled settings. The State's person-centered planning will ensure that
settings continue to remain compliant over time.
Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (1 of 8)
State Participant-Centered Service Plan Title:
Care Plan
Responsibility for Service Plan Development. Per 42 CFR §441.301(b)(2), specify who is responsible for the
development of the service plan and the qualifications of these individuals (select each that applies):
Registered nurse, licensed to practice in the state
Licensed practical or vocational nurse, acting within the scope of practice under state law
Licensed physician (M.D. or D.O)
Case Manager (qualifications specified in Appendix C-1/C-3)
Case Manager (qualifications not specified in Appendix C-1/C-3).
Specify qualifications:
Social Worker
Specify qualifications:
Other
Specify the individuals and their qualifications:
a.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 61 of 118
06/24/2020
Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (2 of 8)
Service Plan Development Safeguards. Select one:
Entities and/or individuals that have responsibility for service plan development may not provide other
direct waiver services to the participant.
Entities and/or individuals that have responsibility for service plan development may provide other
direct waiver services to the participant.
The state has established the following safeguards to ensure that service plan development is conducted in the best
interests of the participant. Specify:
b.
Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (3 of 8)
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.
c.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 62 of 118
06/24/2020
The State ensures that the waiver recipient, or their representative, has the right to actively engage in the development of
the POC, and can include whomever they wish to participate in the planning process. The recipient, or their
representative, reviews and receives a copy of the Rights and Responsibilities, AHCA Form 5000-26, annually which
assures the recipient of their right/responsibility for assisting the care coordinator with development of the POC and for
playing an active role in managing the care that they receive. It is the responsibility of the care coordinator to educate the
recipient, or their representative, of their rights as well as facilitate a participant-centered planning approach. The care
coordinator works with the recipient and family to ensure continuity of care, and to be the link between them and the
services.
The POC will address all health and social service needs of the recipient identified through the assessment. The care
coordinator, along with the recipient, reviews the plan of care every six months or as needed to ensure that services are
meeting the recipient's needs. The care coordinator will then also document the recipient's status, satisfaction with
services and additional service needs. The POC, AHCA Form 5000-27, is then signed by the recipient and or
representative. These steps assure the recipient has participated in the service plan development. This process is
monitored every six months or as needed by AHCA Model Waiver analyst. The Rights and Responsibilities, AHCA
Form 5000-26, is also reviewed during plan of care development process to remind the recipient, legal representative or
family members of their responsibility to be an active part of the care planning process, making sure that the recipients
needs are being met, services are being delivered, and or if their are any problems in obtaining services. They are also
informed that they have the right to have anyone of their choosing present during the care planning process.
The AHCA Form 5000-26 shown below is also reviewed and signed annually to inform and remind the recipient and
their families of their rights and responsibilities as a Model Waiver recipient to be an active part of the care planning
process to ensure that the recipients needs are being met, services are being delivered, and if there are any problems in
obtaining services. Also covered is the right to have anyone that they wish to be present at the care planning process.
MODEL WAIVER
PARTICIPANT RIGHTS AND RESPONSIBILITIES
Your child has been determined eligible to receive home and community based services under the Model Waiver
Program. Under this program you have certain rights and responsibilities on behalf of your child. These include:
I. Freedom of Choice
You have the right to choose care for your child through this Model Waiver program or admission to a hospital.
You have the right to choose the service providers from whom your child will receive Model Waiver services, to the
extent they are available.
You have the right to choose any enrolled care coordinator to the extent they are available and have chosen to participate
in this program.
II. Right of Appeal
If your child is denied a service you believe he or she is eligible to receive, you have the right to appeal the decision.
Pursuant to 42 CFR, Part 431, subpart E, the decision may be appealed by requesting a Fair Hearing by a State Hearings
Office with the Department of Children and Families.
III. Responsibilities
You are responsible for assisting your care coordinator in developing your childs Plan of Care and schedule of services.
You are responsible for notifying your care coordinator when you have problems in obtaining services or when you are
dissatisfied with the care.
You are responsible for following health care instructions to the best of your ability.
I certify that I have received and reviewed a copy of this Model Waiver, Participant Rights and Responsibilities. I agree
to abide by and adhere to the responsibilities listed above.
Parent/Legal Guardian Signature Date
AHCA Form 5000-26
Appendix D: Participant-Centered Planning and Service Delivery
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 63 of 118
06/24/2020
D-1: Service Plan Development (4 of 8)
Service Plan Development Process. In four pages or less, describe the process that is used to develop the participant-
centered service plan, including: (a) who develops the plan, who participates in the process, and the timing of the plan; (b)
the types of assessments that are conducted to support the service plan development process, including securing
information about participant needs, preferences and goals, and health status; (c) how the participant is informed of the
services that are available under the waiver; (d) how the plan development process ensures that the service plan addresses
participant goals, needs (including health care needs), and preferences; (e) how waiver and other services are coordinated;
(f) how the plan development process provides for the assignment of responsibilities to implement and monitor the plan;
and, (g) how and when the plan is updated, including when the participant's needs change. State laws, regulations, and
policies cited that affect the service plan development process are available to CMS upon request through the Medicaid
agency or the operating agency (if applicable):
Care coordinators work with the recipient and the recipient’s parent or guardian to develop and monitor the POC. The
POCs are reviewed every six months, or as needed, in a scheduled meeting of the care coordinator and the recipient and
the recipient’s parent or guardian. The recipient and the recipient’s parent or guardian may invite any other interested
parties including other service providers to the care plan meeting.
Care planning meetings are scheduled in coordination with the recipient and held at times convenient for the recipient
and/or the parent/legal guardian. The meetings can be held in a variety of settings such as the Medicaid area office, the
participant's home, or via a conference call.
During the care plan meeting, the care coordinator verifies that the recipient has access to waiver services identified in
their POC, that the recipient exercise free choice of providers, and that services meet the recipient’s needs. The care
coordinator also reviews State Plan services with the recipient and their parent or guardian during this meeting. At the
end of the care plan meeting the care coordinator documents any identified problems and develops a remediation goal to
address them within 60 calendar days.
The care coordinator maintains ongoing verbal and written communication with the recipient and/or the parent/legal
guardian to keep them informed to available services and ensure recipient satisfaction. Additionally, through monitoring,
the State ensures that POCs include recipients’ personal goals and goals for community integration. The POC may be
updated between the scheduled six-month care plan meetings if circumstances with the recipient change and warrant a
change in the POC.
For recipients transitioning from a nursing home into the community, the transition case manager is required to develop a
service plan to address the specific needs of each candidate. Transitional planning at minimum must include the
following:
• Consultation with recipient, parent, caregivers or guardians, physician, and skilled nursing facility staff;
• Completion of an assessment of the recipients, medical functions, social, cognitive capabilities;
• Identification of formal and informal system of support;
• Documentation of all essential medical equipment, services and supplies;
• Detailed review of living arrangements and if appropriately accessible.
A multidisciplinary team that includes the care coordinator will organize all services for the participant. This all-
inclusive approach increases access to services and minimizes barriers.
d.
Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (5 of 8)
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.
e.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 64 of 118
06/24/2020
Individual risk assessments are part of the plan of care development process for all HCBS waiver recipients including the
Model Waiver. During the scheduled care plan meeting and throughout the year, the care coordinator needs to remain
aware of possible risks that threaten the health, safety, and welfare of the recipient. The care coordinator continually work
with the recipient and the caregiver to assess and identify risks upon development and implementation of the plan of care
and subsequently when the plan of care is reviewed or updated. Individual waiver recipient and their caregiver will be
informed of any identified risks and provided an opportunity to participate in plan of care development to mitigate risk.
Individual waiver recipients retain the right to assume risk and approve of or decline the receipt of services at any time.
The care coordinator addresses any disruption in the care plan services and provides alternate arrangements. The waiver
recipient, care coordinator and the caregiver, if present, work together to provide emergency backup plans and
arrangements in the plan of care in the case of a natural disaster or emergency. If a alternate provider(s) will be used in
the case of an emergency, the care coordinator will notify the provider and alert them to the arrangements made to
provide services in an emergency situation.
Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (6 of 8)
Informed Choice of Providers. Describe how participants are assisted in obtaining information about and selecting from
among qualified providers of the waiver services in the service plan.
All Model Waiver recipients and or their families are allowed their providers of choice. They will usually have had a
relationship with previous providers by the time they are enrolled in the Model Waiver and will choose to use them. If
they have no history with a provider they are educated about their choices of providers in their area by their care
coordinator. The Model Waiver Analyst will help enroll their provider of choice as a Model Waiver provider.
f.
Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (7 of 8)
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 in accordance with 42 CFR §441.301(b)(1)(i):
The Model Waiver analyst is employed with the Agency for Health Care Administration in the Division of Medicaid,
Bureau of Medicaid Policy. This position is responsible for developing policies and procedures pertaining to the waiver
and exercises oversight of all Model waiver operations, including routine review of participant service plans. The Model
Waiver analyst receives a copy of each participant’s service plan bi-annually in order to review the participant’s needs.
g.
Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development (8 of 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. Specify the minimum schedule for the review
and update of the service plan:
Every three months or more frequently when necessary
Every six months or more frequently when necessary
Every twelve months or more frequently when necessary
Other schedule
Specify the other schedule:
h.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 65 of 118
06/24/2020
Maintenance of 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 §92.42. Service plans are maintained by the following (check each that
applies):
Medicaid agency
Operating agency
Case manager
Other
Specify:
i.
Appendix D: Participant-Centered Planning and Service Delivery
D-2: Service Plan Implementation and Monitoring
Service Plan Implementation and Monitoring. Specify: (a) the entity (entities) responsible for monitoring the
implementation of the service plan and participant health and welfare; (b) the monitoring and follow-up method(s) that are
used; and, (c) the frequency with which monitoring is performed.
Model Waiver Specific Case Management/Care Coordinator Requirements
The care coordinator's roles and responsibilities specific to the Model Waiver recipient include:
Complete the plan of care to include amount, duration and frequency of services using Recipient Plan of Care, AHCA
Form 5000-27;
Implement the plan of care including assisting the recipient and family in using supports and services;
Review and update the plan of care every 6 months at a minimum;
Monitor provision of services included in the plan of care;
Initiate and oversee the process of assessment and reassessment of the recipients level of care every 12 months; and
Attend CMAT (Childrens Multi-disciplinary Assessment Team) staffings related to the Model waiver recipient.
Monitoring of Case Management and Plan of Care.
All plans of care are reviewed every six months or as needed to ensure that recipient's assessed needs are addressed in the
care plan and the recipient is being maintained in the home/community in a safe and healthy manner. All Levels of Care
forms are monitored every 12 months or as needed to ensure that a recipient meets the waivers eligibility requirements.
During annual file monitoring, the central records from care coordinators are reviewed to ensure POC meeting case notes
are current and complete, and that waiver documents requiring recipient or guardian signature are included. Interviews
with recipients or guardians are also conducted in order to verify that they have been afforded choice of providers, access
to services that meet identified needs, and to assess the recipient’s satisfaction with services. The State reviews the POC
to determine that required service backup and natural non-paid resources are in place, and that state plan services are
clearly identified in the plan. Any issues or problems resulting from monitoring are addressed by the State by initiating
corrective action with the care coordinator and regular follow up with the recipient, guardians or providers as needed.
a.
Monitoring Safeguards. Select one:
Entities and/or individuals that have responsibility to monitor service plan implementation and
participant health and welfare may not provide other direct waiver services to the participant.
Entities and/or individuals that have responsibility to monitor service plan implementation and
participant health and welfare may provide other direct waiver services to the participant.
The state has established the following safeguards to ensure that monitoring is conducted in the best interests of the
b.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 66 of 118
06/24/2020
participant. Specify:
Appendix D: Participant-Centered Planning and Service Delivery
Quality Improvement: Service Plan
As a distinct component of the States quality improvement strategy, provide information in the following fields to detail the States
methods for discovery and remediation.
Methods for Discovery: Service Plan Assurance/Sub-assurances
The state demonstrates it has designed and implemented an effective system for reviewing the adequacy of service plans
for waiver participants.
Sub-Assurances:
Sub-assurance: Service plans address all participants assessed needs (including health and safety risk
factors) and personal goals, either by the provision of waiver services or through other means.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or
sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to
analyze and assess progress toward the performance measure. In this section provide information on the
method by which each source of data is analyzed statistically/deductively or inductively, how themes are
identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Percentage of recipient POCs documenting assessed needs and personal and
community integration goal setting. Numerator: Number of recipient POCs
documenting assessed needs and personal and community integration goal setting.
Denominator: Number of POCs reviewed.
Data Source (Select one):
Record reviews, on-site
If 'Other' is selected, specify:
Responsible Party for
data
collection/generation
(check each that applies):
Frequency of data
collection/generation
(check each that applies):
Sampling Approach
(check each that applies):
State Medicaid
Agency
Weekly 100% Review
Operating Agency Monthly Less than 100%
Review
Representative
Sample
Confidence
Sub-State Entity Quarterly
a.
i.
a.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 67 of 118
06/24/2020
Interval =
Other
Specify:
Annually Stratified
Describe Group:
Continuously and
Ongoing
Other
Specify:
Other
Specify:
Data Aggregation and Analysis:
Responsible Party for data
aggregation and analysis (check each
that applies):
Frequency of data aggregation and
analysis(check each that applies):
State Medicaid Agency Weekly
Operating Agency Monthly
Sub-State Entity Quarterly
Other
Specify:
Annually
Continuously and Ongoing
Other
Specify:
Sub-assurance: The State monitors service plan development in accordance with its policies and b.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 68 of 118
06/24/2020
procedures.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or
sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to
analyze and assess progress toward the performance measure. In this section provide information on the
method by which each source of data is analyzed statistically/deductively or inductively, how themes are
identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Sub-assurance: Service plans are updated/revised at least annually or when warranted by changes in the
waiver participants needs.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or
sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to
analyze and assess progress toward the performance measure. In this section provide information on the
method by which each source of data is analyzed statistically/deductively or inductively, how themes are
identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Percentage of recipient POCs that were updated/revised at least annually consistent
with assessed needs. Numerator: Number of recipient POCs that were
updated/revised at least annually consistent with assessed needs. Denominator:
Number of POCs reviewed.
Data Source (Select one):
Record reviews, on-site
If 'Other' is selected, specify:
Responsible Party for
data
collection/generation
(check each that applies):
Frequency of data
collection/generation
(check each that applies):
Sampling Approach
(check each that applies):
State Medicaid
Agency
Weekly 100% Review
Operating Agency Monthly Less than 100%
Review
Sub-State Entity Quarterly Representative
Sample
Confidence
Interval =
c.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 69 of 118
06/24/2020
Other
Specify:
Annually Stratified
Describe Group:
Continuously and
Ongoing
Other
Specify:
Other
Specify:
Data Aggregation and Analysis:
Responsible Party for data
aggregation and analysis (check each
that applies):
Frequency of data aggregation and
analysis(check each that applies):
State Medicaid Agency Weekly
Operating Agency Monthly
Sub-State Entity Quarterly
Other
Specify:
Annually
Continuously and Ongoing
Other
Specify:
Sub-assurance: Services are delivered in accordance with the service plan, including the type, scope,
amount, duration and frequency specified in the service plan.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or
d.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 70 of 118
06/24/2020
sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to
analyze and assess progress toward the performance measure. In this section provide information on the
method by which each source of data is analyzed statistically/deductively or inductively, how themes are
identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Percentage of recipients receiving services according to the POC as to service type,
scope, amount, duration, and frequency. Numerator: Number of recipients receiving
services according to the POC as to service type, scope, amount, duration, and
frequency. Denominator: Number of POCs reviewed.
Data Source (Select one):
Record reviews, off-site
If 'Other' is selected, specify:
Responsible Party for
data
collection/generation
(check each that applies):
Frequency of data
collection/generation
(check each that applies):
Sampling Approach
(check each that applies):
State Medicaid
Agency
Weekly 100% Review
Operating Agency Monthly Less than 100%
Review
Sub-State Entity Quarterly Representative
Sample
Confidence
Interval =
Other
Specify:
Annually Stratified
Describe Group:
Continuously and
Ongoing
Other
Specify:
Other
Specify:
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 71 of 118
06/24/2020
Data Aggregation and Analysis:
Responsible Party for data
aggregation and analysis (check each
that applies):
Frequency of data aggregation and
analysis(check each that applies):
State Medicaid Agency Weekly
Operating Agency Monthly
Sub-State Entity Quarterly
Other
Specify:
Annually
Continuously and Ongoing
Other
Specify:
Sub-assurance: Participants are afforded choice: Between/among waiver services and providers.
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or
sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to
analyze and assess progress toward the performance measure. In this section provide information on the
method by which each source of data is analyzed statistically/deductively or inductively, how themes are
identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Percentage of recipients afforded choice of services and service providers.
Numerator: Number of recipients afforded choice of services and service providers.
Denominator: Number of POCs reviewed.
Data Source (Select one):
Record reviews, off-site
If 'Other' is selected, specify:
Responsible Party for
data
collection/generation
(check each that applies):
Frequency of data
collection/generation
(check each that applies):
Sampling Approach
(check each that applies):
State Medicaid
Agency
Weekly 100% Review
e.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 72 of 118
06/24/2020
Operating Agency Monthly Less than 100%
Review
Sub-State Entity Quarterly Representative
Sample
Confidence
Interval =
Other
Specify:
Annually Stratified
Describe Group:
Continuously and
Ongoing
Other
Specify:
Other
Specify:
Data Aggregation and Analysis:
Responsible Party for data
aggregation and analysis (check each
that applies):
Frequency of data aggregation and
analysis(check each that applies):
State Medicaid Agency Weekly
Operating Agency Monthly
Sub-State Entity Quarterly
Other
Specify:
Annually
Continuously and Ongoing
Other
Specify:
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 73 of 118
06/24/2020
Responsible Party for data
aggregation and analysis (check each
that applies):
Frequency of data aggregation and
analysis(check each that applies):
If applicable, in the textbox below provide any necessary additional information on the strategies employed by the
State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
Recipients records will be requested prior to the anniversary of the recipient enrollment into the program. A desk
review will take place, which will include a review of the recipients records covering Plan of Care documentation;
Level of Care documentations, Cost Plans, service coordination and completion of recipients surveys. The review
will end with the completion of a summary of any concerns and/or actions required. A written report shall be
provided to the provider from the Medicaid Services office which will include any quality improvement plan
requirements or recommendations.
ii.
Methods for Remediation/Fixing Individual Problems
Describe the States method for addressing individual problems as they are discovered. Include information
regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on
the methods used by the state to document these items.
A written report from the Medicaid Agency shall be provided to the provider which will include any quality
improvement plan requirements or recommendations.
i.
Remediation Data Aggregation
Remediation-related Data Aggregation and Analysis (including trend identification)
Responsible Party(check each that applies):
Frequency of data aggregation and analysis
(check each that applies):
State Medicaid Agency Weekly
Operating Agency Monthly
Sub-State Entity Quarterly
Other
Specify:
Annually
Continuously and Ongoing
Other
Specify:
ii.
b.
Timelines
When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design
methods for discovery and remediation related to the assurance of Service Plans that are currently non-operational.
c.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 74 of 118
06/24/2020
No
Yes
Please provide a detailed strategy for assuring Service Plans, the specific timeline for implementing identified
strategies, and the parties responsible for its operation.
Appendix E: Participant Direction of Services
Applicability (from Application Section 3, Components of the Waiver Request):
Yes. This waiver provides participant direction opportunities. Complete the remainder of the Appendix.
No. This waiver does not provide participant direction opportunities. Do not complete the remainder of the
Appendix.
CMS urges states to afford all waiver participants the opportunity to direct their services. Participant direction of services
includes the participant exercising decision-making authority over workers who provide services, a participant-managed budget
or both. CMS will confer the Independence Plus designation when the waiver evidences a strong commitment to participant
direction.
Indicate whether Independence Plus designation is requested (select one):
Yes. The state requests that this waiver be considered for Independence Plus designation.
No. Independence Plus designation is not requested.
Appendix E: Participant Direction of Services
E-1: Overview (1 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (2 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (3 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (4 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (5 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 75 of 118
06/24/2020
E-1: Overview (6 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (7 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (8 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (9 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (10 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (11 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (12 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-1: Overview (13 of 13)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-2: Opportunities for Participant Direction (1 of 6)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-2: Opportunities for Participant-Direction (2 of 6)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 76 of 118
06/24/2020
E-2: Opportunities for Participant-Direction (3 of 6)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-2: Opportunities for Participant-Direction (4 of 6)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-2: Opportunities for Participant-Direction (5 of 6)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix E: Participant Direction of Services
E-2: Opportunities for Participant-Direction (6 of 6)
Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.
Appendix F: Participant Rights
Appendix F-1: Opportunity to Request a Fair Hearing
The state provides an opportunity to request a Fair Hearing under 42 CFR Part 431, Subpart E to individuals: (a) who are not
given the choice of home and community-based services as an alternative to the institutional care specified in Item 1-F of the
request; (b) are denied the service(s) of their choice or the provider(s) of their choice; or, (c) whose services are denied,
suspended, reduced or terminated. The state provides notice of action as required in 42 CFR §431.210.
Procedures for Offering 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.
Model Waiver participants, or their legal representatives, are informed of their fair hearing rights when an adverse action has
been taken regarding the participant's Medicaid eligibility or when waiver services are reduced, denied, terminated, or
suspended. Model Waiver participants, or their legal representative, are educated on this information during the enrollment
process, and annually thereafter when the care coordinator reviews the recipients rights and responsibilities when developing the
POC.
The participants' care coordinator informs the recipient of the denial, termination, reduction, or suspension of a waiver service
both verbally and in writing at the time of the adverse action. The participant is also informed (verbally and in writing at the time
of the adverse action) of his or her right to request a Fair Hearing and that their services will continue during the period while the
participants appeal is under consideration with the Department of Children and Families, Office of Appeals.
Notices of adverse actions and requests for a Fair Hearing are maintained in the participants record. The participant is informed
of their right to a Fair Hearing through the denial/reduction notification letter. The State maintains the file that contains all
notices of adverse actions and requests for Fair Hearings. This information is also maintained by the participants' care
coordinator.
If a fair hearing is requested, the participant will receive information regarding the proceedings (date, time, etc.) from the
Department of Children and Families.
Appendix F: Participant-Rights
Appendix F-2: Additional Dispute Resolution Process
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 77 of 118
06/24/2020
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. Select one:
No. This Appendix does not apply
Yes. The state operates an additional dispute resolution process
a.
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: State laws, regulations, and policies referenced in the description are
available to CMS upon request through the operating or Medicaid agency.
b.
Appendix F: Participant-Rights
Appendix F-3: State Grievance/Complaint System
Operation of Grievance/Complaint System. Select one:
No. This Appendix does not apply
Yes. The state operates a grievance/complaint system that affords participants the opportunity to register
grievances or complaints concerning the provision of services under this waiver
a.
Operational Responsibility. Specify the state agency that is responsible for the operation of the grievance/complaint
system:
b.
Description of System. Describe the grievance/complaint system, including: (a) the types of grievances/complaints that
participants may register; (b) the process and timelines for addressing grievances/complaints; and, (c) the mechanisms that
are used to resolve grievances/complaints. State laws, regulations, and policies referenced in the description are available
to CMS upon request through the Medicaid agency or the operating agency (if applicable).
c.
Appendix G: Participant Safeguards
Appendix G-1: Response to Critical Events or Incidents
Critical Event or Incident Reporting and Management Process. Indicate whether the state operates Critical Event or
Incident Reporting and Management Process that enables the state to collect information on sentinel events occurring in
the waiver program.Select one:
Yes. The state operates a Critical Event or Incident Reporting and Management Process (complete Items b
through e)
No. This Appendix does not apply (do not complete Items b through e)
If the state does not operate a Critical Event or Incident Reporting and Management Process, describe the process that
the state uses to elicit information on the health and welfare of individuals served through the program.
a.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 78 of 118
06/24/2020
State Critical Event or Incident Reporting Requirements. Specify the types of critical events or incidents (including
alleged abuse, neglect and exploitation) that the state requires to be reported for review and follow-up action by an
appropriate authority, the individuals and/or entities that are required to report such events and incidents and the timelines
for reporting. State laws, regulations, and policies that are referenced are available to CMS upon request through the
Medicaid agency or the operating agency (if applicable).
Model Waiver providers are required to report to the Agency for Health Care Administration headquarters within 24
hours if any of the following events occur:
1. death of a participant due to any means; 2. participant injury or illness that requires emergency medical treatment that
was sustained due to an accident, act of abuse, neglect or other incident; 3. allegation of sexual battery; or 4. elopement.
A critical event form is provided to all enrolled providers by Medicaid Services staff for the purpose of reporting critical
events or incidents.
All critical event forms are to be sent to the Florida Department of Children and Families either through fax, or
electronically.
b.
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.
During the plan of care development, the care coordinator educates the recipient and or their legal representative about
abuse, neglect, and exploitation reporting. The recipient or representative is given Florida's toll-free abuse reporting
hotline (1-800-96-ABUSE) operated by the Department of Children and Families. The MW recipient and or their legal
representative is also encouraged to notify their care coordinator immediately of any incident where the participant feels
they have been abused, neglected, or exploited. The care coordinator is a mandatory reporter by Florida Statutes Chapter
39 to report immediately any suspicion of abuse, neglect, or exploitation. Investigations are conducted by the
Department of Children and Families within their established timeframes.
When the State is made aware of critical incidents, immediate action is taken to notify the appropriate entities, mainly the
Department of Children and Families. In addition, during the plan of care development, the CMAT nurse educates the
recipient and or their legal representative about abuse, neglect, and exploitation reporting. The beneficiary or
representative is given Florida's toll-free abuse reporting hotline (1-800-96-ABUSE) operated by the Department of
Children and Families.
The Department of Children and Families makes every effort to act with a sense of urgency to all allegations of harm to
children and/or vulnerable adults. The Florida Abuse Hotline strives to submit all reports to the appropriate investigative
office within one hour after the call to the Hotline ends. Once the report arrives at the investigative office and is assigned
to an investigator, the investigator has up to 24 hours to initiate contact with the subjects of the report. In situations in
which it is believed the victim is at imminent risk of harm, the investigator will respond as soon as possible.
The Department of Children and Families has 60 days to complete their investigation and to notify relevant parties per
Florida Statutes. Florida Statutes determine who is entitled to a copy of a report of abuse, neglect, or exploitation of a
child or vulnerable adult. The participants family or legal representative (and other relevant parties meeting the statutory
requirements) can also receive a copy of the investigation results by contacting the Department of Children and Families
child or adult investigative office in the county where the investigation occurred.
The State’s contracted vendor is responsible for preparing a comprehensive provider training plan that addresses the
provider’s initial and ongoing training needs for all aspects of the services under the contract.
c.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 79 of 118
06/24/2020
Responsibility for Review of and Response to Critical Events or Incidents. Specify the entity (or entities) that receives
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.
The Florida Department of Children and Families (DCF) receives reports of abuse, neglect, and exploitation of vulnerable
adults through its management of the statewide abuse reporting hotline. DCF responds to critical events or incidents
through referrals to the Adult Protective Services program or local law enforcement for investigation as required by
Chapter 415, Florida Statutes.
d.
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.
The Agency for Health Care Administration, in partnership with the Florida Department of Children and Families and the
Florida Department of Law Enforcement, are responsible for overseeing the reporting of and response to critical incidents
or events for participants of this waiver as they occur. The State addresses all critical incidents as appropriate and data is
collected and aggregated daily as necessary. These entities communicate via email and phone on an as needed basis to
coordinate oversight of the reporting of and response to critical incidents or events that affect waiver participants. The
investigating entity is required to report findings on required actions for remediation back to the State via email, letter,
and phone. As a part of their regular recipient contact, waiver care coordinators must review the topic of critical
incidents, including ensuring that recipients are aware of how to report an incident as well as offering recipients an
opportunity to report incidents.
e.
Appendix G: Participant Safeguards
Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (1 of
3)
Use of Restraints. (Select one): (For waiver actions submitted before March 2014, responses in Appendix G-2-a will
display information for both restraints and seclusion. For most waiver actions submitted after March 2014, responses
regarding seclusion appear in Appendix G-2-c.)
The state does not permit or prohibits the use of restraints
Specify the state agency (or agencies) responsible for detecting the unauthorized use of restraints and how this
oversight is conducted and its frequency:
Allegations of prohibited use of restraints or seclusion by a Model Waiver provider may be reported by provider or
participant directly to the local Florida Department of Children and Families office and to the Florida Medicaid
Agencys central office. Agencies will be required to keep a log of any use of seclusion and restraint and staff will
review logs on a monthly basis. The State monitors the unauthorized use of restraints through annual provider
reviews conducted by the State and during conference calls with the care coordinators.
The use of restraints is permitted during the course of the delivery of waiver services. Complete Items G-2-a-i
and G-2-a-ii.
Safeguards Concerning the Use of Restraints. Specify the safeguards that the state has established
concerning the use of each type of restraint (i.e., personal restraints, drugs used as restraints, mechanical
restraints). State laws, regulations, and policies that are referenced are available to CMS upon request through
the Medicaid agency or the operating agency (if applicable).
i.
State Oversight Responsibility. Specify the state agency (or agencies) responsible for overseeing the use of ii.
a.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 80 of 118
06/24/2020
restraints and ensuring that state safeguards concerning their use are followed and how such oversight is
conducted and its frequency:
Appendix G: Participant Safeguards
Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (2 of
3)
Use of Restrictive Interventions. (Select one):
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:
Allegations of prohibited use of restraints or seclusion by a Model Waiver provider may be reported by provider or
participant directly to the local Florida Department of Children and Families office and to the Florida Medicaid
Agencys central office. Agencies will be required to keep a log of any use of seclusion and restraint and staff will
review logs on a monthly basis.
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.
Safeguards Concerning the Use of Restrictive Interventions. Specify the safeguards that the state has in
effect concerning the use of interventions that restrict participant movement, participant access to other
individuals, locations or activities, restrict participant rights or employ aversive methods (not including
restraints or seclusion) to modify behavior. State laws, regulations, and policies referenced in the specification
are available to CMS upon request through the Medicaid agency or the operating agency.
i.
State Oversight Responsibility. Specify the state agency (or agencies) responsible for monitoring and
overseeing the use of restrictive interventions and how this oversight is conducted and its frequency:
ii.
b.
Appendix G: Participant Safeguards
Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (3 of
3)
Use of Seclusion. (Select one): (This section will be blank for waivers submitted before Appendix G-2-c was added to
WMS in March 2014, and responses for seclusion will display in Appendix G-2-a combined with information on
restraints.)
The state does not permit or prohibits the use of seclusion
Specify the state agency (or agencies) responsible for detecting the unauthorized use of seclusion and how this
oversight is conducted and its frequency:
c.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 81 of 118
06/24/2020
Allegations of prohibited use of restraints or seclusion by a Model Waiver provider may be reported by provider or
participant directly to the local Florida Department of Children and Families office and to the Florida Medicaid
Agency's central office. Agencies will be required to keep a log of any use of seclusion and restraint and staff will
review logs on a monthly basis.
The use of seclusion is permitted during the course of the delivery of waiver services. Complete Items G-2-c-i
and G-2-c-ii.
Safeguards Concerning the Use of Seclusion. Specify the safeguards that the state has established
concerning the use of each type of seclusion. State laws, regulations, and policies that are referenced are
available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
i.
State Oversight Responsibility. Specify the state agency (or agencies) responsible for overseeing the use of
seclusion and ensuring that state safeguards concerning their use are followed and how such oversight is
conducted and its frequency:
ii.
Appendix G: Participant Safeguards
Appendix G-3: Medication Management and Administration (1 of 2)
This Appendix must be completed when waiver services are furnished to participants who are served in licensed or unlicensed
living arrangements where a provider has round-the-clock responsibility for the health and welfare of residents. The Appendix
does not need to be completed when waiver participants are served exclusively in their own personal residences or in the home of
a family member.
Applicability. Select one:
No. This Appendix is not applicable (do not complete the remaining items)
Yes. This Appendix applies (complete the remaining items)
a.
Medication Management and Follow-Up
Responsibility. Specify the entity (or entities) that have ongoing responsibility for monitoring participant
medication regimens, the methods for conducting monitoring, and the frequency of monitoring.
i.
Methods of State Oversight and Follow-Up. Describe: (a) the method(s) that the state uses to ensure that
participant medications are managed appropriately, including: (a) the identification of potentially harmful practices
(e.g., the concurrent use of contraindicated medications); (b) the method(s) for following up on potentially harmful
practices; and, (c) the state agency (or agencies) that is responsible for follow-up and oversight.
ii.
b.
Appendix G: Participant Safeguards
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 82 of 118
06/24/2020
Appendix G-3: Medication Management and Administration (2 of 2)
Medication Administration by Waiver Providers
Answers provided in G-3-a indicate you do not need to complete this section
Provider Administration of Medications. Select one:
Not applicable. (do not complete the remaining items)
Waiver providers are responsible for the administration of medications to waiver participants who
cannot self-administer and/or have responsibility to oversee participant self-administration of
medications. (complete the remaining items)
i.
State Policy. Summarize the state policies that apply to the administration of medications by waiver providers or
waiver provider responsibilities when participants self-administer medications, including (if applicable) policies
concerning medication administration by non-medical waiver provider personnel. State laws, regulations, and
policies referenced in the specification are available to CMS upon request through the Medicaid agency or the
operating agency (if applicable).
ii.
Medication Error Reporting. Select one of the following:
Providers that are responsible for medication administration are required to both record and report
medication errors to a state agency (or agencies).
Complete the following three items:
(a) Specify state agency (or agencies) to which errors are reported:
(b) Specify the types of medication errors that providers are required to record:
(c) Specify the types of medication errors that providers must report to the state:
Providers responsible for medication administration are required to record medication errors but make
information about medication errors available only when requested by the state.
Specify the types of medication errors that providers are required to record:
iii.
State Oversight Responsibility. Specify the state agency (or agencies) responsible for monitoring the performance iv.
c.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 83 of 118
06/24/2020
of waiver providers in the administration of medications to waiver participants and how monitoring is performed
and its frequency.
Appendix G: Participant Safeguards
Quality Improvement: Health and Welfare
As a distinct component of the States quality improvement strategy, provide information in the following fields to detail the States
methods for discovery and remediation.
Methods for Discovery: Health and Welfare
The state demonstrates it has designed and implemented an effective system for assuring waiver participant health and
welfare. (For waiver actions submitted before June 1, 2014, this assurance read "The State, on an ongoing basis,
identifies, addresses, and seeks to prevent the occurrence of abuse, neglect and exploitation.")
Sub-Assurances:
Sub-assurance: The state demonstrates on an ongoing basis that it identifies, addresses and seeks to
prevent instancesof abuse, neglect, exploitation and unexplained death. (Performance measures in this
sub-assurance include all Appendix G performance measures for waiver actions submitted before June 1,
2014.)
Performance Measures
For each performance measure the State will use to assess compliance with the statutory assurance (or
sub-assurance), complete the following. Where possible, include numerator/denominator.
For each performance measure, provide information on the aggregated data that will enable the State to
analyze and assess progress toward the performance measure. In this section provide information on the
method by which each source of data is analyzed statistically/deductively or inductively, how themes are
identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Percentage of participants reporting they received information/education about how
to report abuse neglect, exploitation and other critical events Numerator: Number of
participants reporting they received information/education about how to report
abuse neglect, exploitation and other critical events Denominator: Number of
participants receiving Model Waiver services
Data Source (Select one):
Record reviews, on-site
If 'Other' is selected, specify:
Responsible Party for
data
collection/generation
(check each that applies):
Frequency of data
collection/generation
(check each that applies):
Sampling Approach
(check each that applies):
State Medicaid
Agency
Weekly 100% Review
Operating Agency Monthly Less than 100%
Review
a.
i.
a.
Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 84 of 118
06/24/2020
Sub-State Entity Quarterly Representative