Fill - Free fillable Application for a 1915(c) Home and Community- Based (Florida) PDF form

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

§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

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

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

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

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

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

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

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

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

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

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

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

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

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 policies and procedures for the use or prohibition of restrictive interventions

(including restraints and seclusion) are followed.

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 who did not have an incident where prohibited restraints

and/or seclusion was used. Numerator: Number of participants who did not have and

incident where prohibited restraints and/or seclusion was used Denominator:

Number of participants records reviewed

Data Source (Select one):

Record reviews, on-site

If 'Other' is selected, specify:

c.

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 90 of 118

06/24/2020

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

Sub-State Entity Quarterly

Other

Specify:

Annually

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 91 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):

Continuously and Ongoing

Other

Specify:

Sub-assurance: The state establishes overall health care standards and monitors those standards based

on the responsibility of the service provider as stated 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.

Performance Measure:

Percentage of participants whose special health requirements or safety needs were

met Numerator: Number of participants whose special health requirements or safety

needs were met Denominator: Number of participants with special health care

requirements

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

Interval =

Sub-State Entity Quarterly

d.

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 92 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:

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 93 of 118

06/24/2020

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 shall be provided to the provider from the Medicaid Agency, 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 Health and Welfare that are currently non-operational.

No

Yes

Please provide a detailed strategy for assuring Health and Welfare, the specific timeline for implementing identified

strategies, and the parties responsible for its operation.

c.

Appendix H: Quality Improvement Strategy (1 of 3)

Under §1915(c) of the Social Security Act and 42 CFR §441.302, the approval of an HCBS waiver requires that CMS determine

that the state has made satisfactory assurances concerning the protection of participant health and welfare, financial accountability

and other elements of waiver operations. Renewal of an existing waiver is contingent upon review by CMS and a finding by CMS

that the assurances have been met. By completing the HCBS waiver application, the state specifies how it has designed the

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 94 of 118

06/24/2020

waiver’s critical processes, structures and operational features in order to meet these assurances.

Quality Improvement is a critical operational feature that an organization employs to continually determine whether it

operates in accordance with the approved design of its program, meets statutory and regulatory assurances and

requirements, achieves desired outcomes, and identifies opportunities for improvement.

■

CMS recognizes that a state’s waiver Quality Improvement Strategy may vary depending on the nature of the waiver target

population, the services offered, and the waiver’s relationship to other public programs, and will extend beyond regulatory

requirements. However, for the purpose of this application, the state is expected to have, at the minimum, systems in place to

measure and improve its own performance in meeting six specific waiver assurances and requirements.

It may be more efficient and effective for a Quality Improvement Strategy to span multiple waivers and other long-term care

services. CMS recognizes the value of this approach and will ask the state to identify other waiver programs and long-term care

services that are addressed in the Quality Improvement Strategy.

Quality Improvement Strategy: Minimum Components

The Quality Improvement Strategy that will be in effect during the period of the approved waiver is described throughout the

waiver in the appendices corresponding to the statutory assurances and sub-assurances. Other documents cited must be available

to CMS upon request through the Medicaid agency or the operating agency (if appropriate).

In the QIS discovery and remediation sections throughout the application (located in Appendices A, B, C, D, G, and I) , a state

spells out:

The evidence based discovery activities that will be conducted for each of the six major waiver assurances; and

■

The remediation activities followed to correct individual problems identified in the implementation of each of the

assurances.

■

In Appendix H of the application, a state describes (1) the system improvement activities followed in response to aggregated,

analyzed discovery and remediation information collected on each of the assurances; (2) the correspondent roles/responsibilities

of those conducting assessing and prioritizing improving system corrections and improvements; and (3) the processes the state

will follow to continuously assess the effectiveness of the OIS and revise it as necessary and appropriate.

If the state's Quality Improvement Strategy is not fully developed at the time the waiver application is submitted, the state may

provide a work plan to fully develop its Quality Improvement Strategy, including the specific tasks the state plans to undertake

during the period the waiver is in effect, the major milestones associated with these tasks, and the entity (or entities) responsible

for the completion of these tasks.

When the Quality Improvement Strategy spans more than one waiver and/or other types of long-term care services under the

Medicaid state plan, specify the control numbers for the other waiver programs and/or identify the other long-term services that

are addressed in the Quality Improvement Strategy. In instances when the QIS spans more than one waiver, the state must be able

to stratify information that is related to each approved waiver program. Unless the state has requested and received approval from

CMS for the consolidation of multiple waivers for the purpose of reporting, then the state must stratify information that is related

to each approved waiver program, i.e., employ a representative sample for each waiver.

Appendix H: Quality Improvement Strategy (2 of 3)

H-1: Systems Improvement

System Improvements

Describe the process(es) for trending, prioritizing, and implementing system improvements (i.e., design changes)

prompted as a result of an analysis of discovery and remediation information.

i.

a.

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 95 of 118

06/24/2020

description of the various roles and responsibilities involved in the processes for monitoring & assessing system

design changes. If applicable, include the state's targeted standards for systems improvement.

Florida's Home and Community-Based Waiver for individuals with degenerative spino-cerebellar disease was

implemented in 1991 and called the Model Waiver formerly known as the Katie Beckett Waiver. There are

currently five recipients enrolled in the waiver (the CMS 372 report completed December 30, 2019, showed five

(5) unduplicated waiver recipients and $5,184.00 claims billed for respite care and environmental

adaptation/home remodeling as the only two waiver services billed out of the four waiver services offered).

Monitoring guidelines and forms were developed by the Medicaid Agency with input from Children's Medical

Services.

Medicaid Services utilizes multiple oversight activities to ensure that waiver assurances are met. Oversight

activities include: inspection of records, and interviews with waiver recipients and their families. Because of the

small number of recipients in this waiver any problem found or reported is addressed immediately by the

Medicaid Agency to the appropriate parties involved.

A file review was conducted for all recipients in December 2019. Files were monitored for the following items:

Current Level of Care forms (AHCA form 5000-28)

Current Plan of Care (AHCA form 5000- 27)

Current Children's Multi-disciplinary Assessment Team (CMAT) summary assessment

Current Participant Rights and Responsibilities form (AHCA 5000-26)

Confirm all MW providers meet required licensing and or certification standards and adhere to other state

standards on a periodic basis.

Confirm that all MW care coordinators are registered nurses as required by the Model Waiver and have received

annual training has been received.

For files missing any of these documents, the CMAT nurse and the care coordinator were contacted to supply a

copy from the recipients central record. In addition, historical and miscellaneous documents (correspondence,

detailed medical information, etc) were reviewed. File reviews will be conducted annually for all recipients and

providers. The Medicaid Agency continues to conduct annual interviews with recipients and their guardians.

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 recipient's POC specifies and services that the waiver

recipients are receiving. During these interviews, the Medicaid Agency will continue to educate recipients and

their guardians on how to report concerns or incidence of abuse, neglect, and exploitation. Due to the small total

enrollment, the Medicaid Agency will continue to interview 100% of Model Waiver recipients annually.

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

The Medicaid Agency evaluates the program to assess its successes and changes that may be needed through

annual recipient interviews, claims data review, recipient file review, and performance measure monitoring.

ii.

Appendix H: Quality Improvement Strategy (3 of 3)

H-2: Use of a Patient Experience of Care/Quality of Life Survey

Specify whether the state has deployed a patient experience of care or quality of life survey for its HCBS population

in the last 12 months (Select one):

No

Yes (Complete item H.2b)

a.

Specify the type of survey tool the state uses:

HCBS CAHPS Survey :

b.

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 97 of 118

06/24/2020

NCI Survey :

NCI AD Survey :

Other (Please provide a description of the survey tool used):

Appendix I: Financial Accountability

I-1: Financial Integrity and Accountability

Financial Integrity. Describe the methods that are employed to ensure the integrity of payments that have been made for

waiver services, including: (a) requirements concerning the independent audit of provider agencies; (b) the financial audit

program that the state conducts to ensure the integrity of provider billings for Medicaid payment of waiver services,

including the methods, scope and frequency of audits; and, (c) the agency (or agencies) responsible for conducting the

financial audit program. 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).

Financial accountability for the Model Waiver is managed through the Agency for Health Care Administration. Financial

accountability is assured through the State's automated management accounting system and the accounting procedures

manuals, which include federal reporting requirements. All participant, provider, and service utilization/payment data will

be available through the approved federally certified Florida Medicaid Management Information System (FMMIS) that is

designed and operated by a contracted entity and managed by the Agency for Health Care Administration.

The Agency for Health Care Administration is responsible for initial and ongoing monitoring of providers. Providers are

not required to audit their financial statements independently. During the monitoring process, providers' qualifications to

render services and the documentation required to maintain in their files are reviewed. The documentation includes level of

care assessment, plan of care, documentation of service delivery, and billing claims. The monitoring occurs on an annual

basis and looks at 100% of the providers and 100% of the participants.

Medicaid Program Integrity (MPI) within the Agency for Health Care Administration does comprehensive reviews of

providers to identify fraud, waste, and abuse. Potential identification of fraud is referred to the Office of the Attorney

General, Medicaid Fraud Control Unit. Waste and abuse are investigated by MPI. The MPI audit is a comprehensive,

more in-depth audit of the provider’s practice and must be defensible in an Administrative Hearing. MPI reviews

compliance with federal and state laws, rules and promulgated Medicaid policy, including qualifications of all staff, service

documentation, and comparison of both eligibility and documentation to billing and reimbursement. MPI identifies

overpayments and applies sanctions to the provider.

Appendix I: Financial Accountability

Quality Improvement: Financial Accountability

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: Financial Accountability Assurance:

The State must demonstrate that it has designed and implemented an adequate system for ensuring financial

accountability of the waiver program. (For waiver actions submitted before June 1, 2014, this assurance read "State

financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology

specified in the approved waiver.")

Sub-Assurances:

Sub-assurance: The State provides evidence that claims are coded and paid for in accordance with the

reimbursement methodology specified in the approved waiver and only for services rendered.

(Performance measures in this sub-assurance include all Appendix I performance measures for waiver

a.

i.

a.

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 98 of 118

06/24/2020

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 claims paid for services that match the recipient's POC. Numerator:

Number of claims paid for services that match the recipient's POC. Denominator:

Number of claims 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 99 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:

Performance Measure:

Percentage of claims adhering to the Model Waiver rate table. Numerator: Number of

claims adhering to the Model Waiver rate table. Denominator: Number of claims.

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

Interval =

Sub-State Entity Quarterly

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 100 of 118

06/24/2020

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 claims paid at the correct rate, in accordance with policy requirements

and the rate in the fee schedule. N: Number of claims paid at the correct rate, in

accordance with policy requirements and the rate in the fee schedule. D: Total number

of claims paid.

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 102 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.

The integrity of payments are ensured through the Medicaid Agency's claim system for the Medicaid program, the

Florida Medicaid Management Information System (FMMIS).

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.

Financial Audits are conducted by the Medicaid Agency and the Auditor General's Office.

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

ii.

b.

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 103 of 118

06/24/2020

Appendix I: Financial Accountability

I-2: Rates, Billing and Claims (2 of 3)

Certifying Public Expenditures (select one):

No. state or local government agencies do not certify expenditures for waiver services.

Yes. state or local government agencies directly expend funds for part or all of the cost of waiver services

and certify their state government expenditures (CPE) in lieu of billing that amount to Medicaid.

Select at least one:

Certified Public Expenditures (CPE) of State Public Agencies.

Specify: (a) the state government agency or agencies that certify public expenditures for waiver services; (b)

how it is assured that the CPE is based on the total computable costs for waiver services; and, (c) how the state

verifies that the certified public expenditures are eligible for Federal financial participation in accordance with

42 CFR §433.51(b).(Indicate source of revenue for CPEs in Item I-4-a.)

Certified Public Expenditures (CPE) of Local Government Agencies.

Specify: (a) the local government agencies that incur certified public expenditures for waiver services; (b) how it

is assured that the CPE is based on total computable costs for waiver services; and, (c) how the state verifies

that the certified public expenditures are eligible for Federal financial participation in accordance with 42 CFR

§433.51(b). (Indicate source of revenue for CPEs in Item I-4-b.)

c.

Appendix I: Financial Accountability

I-2: Rates, Billing and Claims (3 of 3)

Billing Validation Process. Describe the process for validating provider billings to produce the claim for federal financial

participation, including the mechanism(s) to assure that all claims for payment are made only: (a) when the individual

was eligible for Medicaid waiver payment on the date of service; (b) when the service was included in the participant's

approved service plan; and, (c) the services were provided:

The Florida Medicaid Management Information System (FMMIS) system has recipient eligibility and provider

subsystems. The recipient subsystem is updated as part of the eligibility redetermination process. When a recipient is

enrolled in this waiver it will be reflected on his/her eligibility file. A file in the provider subsystem is established upon

enrollment of a provider. Payments will be reflected on the provider's file. Edits in FMMIS are designed to ensure that

payments for waiver services are made only for authorized waiver services to eligible recipients rendered by enrolled

providers.

The FMMIS system has edits to ensure that, prior to generating a payment, the participant is currently eligible for

Medicaid in an eligibility category approved for the waiver and is enrolled in this waiver. In addition, nurse case

managment monitoring will include review of payments to ensure that services were provided and were included in the

participants approved plan of care.

d.

Billing and Claims Record Maintenance Requirement. Records documenting the audit trail of adjudicated claims e.

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 105 of 118

06/24/2020

(including supporting documentation) are maintained by the Medicaid agency, the operating agency (if applicable), and

providers of waiver services for a minimum period of 3 years as required in 45 CFR §92.42.

Appendix I: Financial Accountability

I-3: Payment (1 of 7)

Method of payments -- MMIS (select one):

Payments for all waiver services are made through an approved Medicaid Management Information System

(MMIS).

Payments for some, but not all, waiver services are made through an approved MMIS.

Specify: (a) the waiver services that are not paid through an approved MMIS; (b) the process for making such

payments and the entity that processes payments; (c) and how an audit trail is maintained for all state and federal

funds expended outside the MMIS; and, (d) the basis for the draw of federal funds and claiming of these expenditures

on the CMS-64:

Payments for waiver services are not made through an approved MMIS.

Specify: (a) the process by which payments are made and the entity that processes payments; (b) how and through

which system(s) the payments are processed; (c) how an audit trail is maintained for all state and federal funds

expended outside the MMIS; and, (d) the basis for the draw of federal funds and claiming of these expenditures on

the CMS-64:

Payments for waiver services are made by a managed care entity or entities. The managed care entity is paid a

monthly capitated payment per eligible enrollee through an approved MMIS.

Describe how payments are made to the managed care entity or entities:

a.

Appendix I: Financial Accountability

I-3: Payment (2 of 7)

Direct payment. In addition to providing that the Medicaid agency makes payments directly to providers of waiver

services, payments for waiver services are made utilizing one or more of the following arrangements (select at least one):

The Medicaid agency makes payments directly and does not use a fiscal agent (comprehensive or limited) or a

managed care entity or entities.

The Medicaid agency pays providers through the same fiscal agent used for the rest of the Medicaid program.

The Medicaid agency pays providers of some or all waiver services through the use of a limited fiscal agent.

Specify the limited fiscal agent, the waiver services for which the limited fiscal agent makes payment, the functions

that the limited fiscal agent performs in paying waiver claims, and the methods by which the Medicaid agency

oversees the operations of the limited fiscal agent:

b.

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 106 of 118

06/24/2020

Providers are paid by a managed care entity or entities for services that are included in the state's contract with the

entity.

Specify how providers are paid for the services (if any) not included in the state's contract with managed care

entities.

Appendix I: Financial Accountability

I-3: Payment (3 of 7)

Supplemental or Enhanced Payments. Section 1902(a)(30) requires that payments for services be consistent with

efficiency, economy, and quality of care. Section 1903(a)(1) provides for Federal financial participation to states for

expenditures for services under an approved state plan/waiver. Specify whether supplemental or enhanced payments are

made. Select one:

No. The state does not make supplemental or enhanced payments for waiver services.

Yes. The state makes supplemental or enhanced payments for waiver services.

Describe: (a) the nature of the supplemental or enhanced payments that are made and the waiver services for which

these payments are made; (b) the types of providers to which such payments are made; (c) the source of the non-

Federal share of the supplemental or enhanced payment; and, (d) whether providers eligible to receive the

supplemental or enhanced payment retain 100% of the total computable expenditure claimed by the state to CMS.

Upon request, the state will furnish CMS with detailed information about the total amount of supplemental or

enhanced payments to each provider type in the waiver.

c.

Appendix I: Financial Accountability

I-3: Payment (4 of 7)

Payments to state or Local Government Providers. Specify whether state or local government providers receive payment

for the provision of waiver services.

No. State or local government providers do not receive payment for waiver services. Do not complete Item I-3-e.

Yes. State or local government providers receive payment for waiver services. Complete Item I-3-e.

Specify the types of state or local government providers that receive payment for waiver services and the services that

the state or local government providers furnish:

d.

Appendix I: Financial Accountability

I-3: Payment (5 of 7)

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 107 of 118

06/24/2020

Amount of Payment to State or Local Government Providers.

Specify whether any state or local government provider receives payments (including regular and any supplemental

payments) that in the aggregate exceed its reasonable costs of providing waiver services and, if so, whether and how the

state recoups the excess and returns the Federal share of the excess to CMS on the quarterly expenditure report. Select

one:

Answers provided in Appendix I-3-d indicate that you do not need to complete this section.

The amount paid to state or local government providers is the same as the amount paid to private providers

of the same service.

The amount paid to state or local government providers differs from the amount paid to private providers of

the same service. No public provider receives payments that in the aggregate exceed its reasonable costs of

providing waiver services.

The amount paid to state or local government providers differs from the amount paid to private providers of

the same service. When a state or local government provider receives payments (including regular and any

supplemental payments) that in the aggregate exceed the cost of waiver services, the state recoups the excess

and returns the federal share of the excess to CMS on the quarterly expenditure report.

Describe the recoupment process:

e.

Appendix I: Financial Accountability

I-3: Payment (6 of 7)

Provider Retention of Payments. Section 1903(a)(1) provides that Federal matching funds are only available for

expenditures made by states for services under the approved waiver. Select one:

Providers receive and retain 100 percent of the amount claimed to CMS for waiver services.

Providers are paid by a managed care entity (or entities) that is paid a monthly capitated payment.

Specify whether the monthly capitated payment to managed care entities is reduced or returned in part to the state.

f.

Appendix I: Financial Accountability

I-3: Payment (7 of 7)

Additional Payment Arrangements

Voluntary Reassignment of Payments to a Governmental Agency. Select one:

No. The state does not provide that providers may voluntarily reassign their right to direct payments

to a governmental agency.

Yes. Providers may voluntarily reassign their right to direct payments to a governmental agency as

provided in 42 CFR §447.10(e).

Specify the governmental agency (or agencies) to which reassignment may be made.

i.

g.

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 108 of 118

06/24/2020

Organized Health Care Delivery System. Select one:

No. The state does not employ Organized Health Care Delivery System (OHCDS) arrangements

under the provisions of 42 CFR §447.10.

Yes. The waiver provides for the use of Organized Health Care Delivery System arrangements under

the provisions of 42 CFR §447.10.

Specify the following: (a) the entities that are designated as an OHCDS and how these entities qualify for

designation as an OHCDS; (b) the procedures for direct provider enrollment when a provider does not

voluntarily agree to contract with a designated OHCDS; (c) the method(s) for assuring that participants have

free choice of qualified providers when an OHCDS arrangement is employed, including the selection of

providers not affiliated with the OHCDS; (d) the method(s) for assuring that providers that furnish services

under contract with an OHCDS meet applicable provider qualifications under the waiver; (e) how it is

assured that OHCDS contracts with providers meet applicable requirements; and, (f) how financial

accountability is assured when an OHCDS arrangement is used:

ii.

Contracts with MCOs, PIHPs or PAHPs.

The state does not contract with MCOs, PIHPs or PAHPs for the provision of waiver services.

The state contracts with a Managed Care Organization(s) (MCOs) and/or prepaid inpatient health plan(s)

(PIHP) or prepaid ambulatory health plan(s) (PAHP) under the provisions of §1915(a)(1) of the Act for the

delivery of waiver and other services. Participants may voluntarily elect to receive waiver and other services

through such MCOs or prepaid health plans. Contracts with these health plans are on file at the state

Medicaid agency.

Describe: (a) the MCOs and/or health plans that furnish services under the provisions of §1915(a)(1); (b) the

geographic areas served by these plans; (c) the waiver and other services furnished by these plans; and, (d)

how payments are made to the health plans.

This waiver is a part of a concurrent §1915(b)/§1915(c) waiver. Participants are required to obtain waiver

and other services through a MCO and/or prepaid inpatient health plan (PIHP) or a prepaid ambulatory

health plan (PAHP). The §1915(b) waiver specifies the types of health plans that are used and how

payments to these plans are made.

This waiver is a part of a concurrent ?1115/?1915(c) waiver. Participants are required to obtain waiver and

other services through a MCO and/or prepaid inpatient health plan (PIHP) or a prepaid ambulatory health

plan (PAHP). The ?1115 waiver specifies the types of health plans that are used and how payments to these

plans are made.

If the state uses more than one of the above contract authorities for the delivery of waiver services, please

select this option.

In the textbox below, indicate the contract authorities. In addition, if the state contracts with MCOs, PIHPs,

or PAHPs under the provisions of §1915(a)(1) of the Act to furnish waiver services: Participants may

voluntarily elect to receive waiver and other services through such MCOs or prepaid health plans. Contracts

with these health plans are on file at the state Medicaid agency. Describe: (a) the MCOs and/or health plans

iii.

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 109 of 118

06/24/2020

that furnish services under the provisions of §1915(a)(1); (b) the geographic areas served by these plans; (c)

the waiver and other services furnished by these plans; and, (d) how payments are made to the health plans.

Appendix I: Financial Accountability

I-4: Non-Federal Matching Funds (1 of 3)

State Level Source(s) of the Non-Federal Share of Computable Waiver Costs. Specify the state source or sources of the

non-federal share of computable waiver costs. Select at least one:

Appropriation of State Tax Revenues to the State Medicaid agency

Appropriation of State Tax Revenues to a State Agency other than the Medicaid Agency.

If the source of the non-federal share is appropriations to another state agency (or agencies), specify: (a) the state

entity or agency receiving appropriated funds and (b) the mechanism that is used to transfer the funds to the

Medicaid Agency or Fiscal Agent, such as an Intergovernmental Transfer (IGT), including any matching

arrangement, and/or, indicate if the funds are directly expended by state agencies as CPEs, as indicated in Item I-2-

c:

Other State Level Source(s) of Funds.

Specify: (a) the source and nature of funds; (b) the entity or agency that receives the funds; and, (c) the mechanism

that is used to transfer the funds to the Medicaid Agency or Fiscal Agent, such as an Intergovernmental Transfer

(IGT), including any matching arrangement, and/or, indicate if funds are directly expended by state agencies as

CPEs, as indicated in Item I-2-c:

a.

Appendix I: Financial Accountability

I-4: Non-Federal Matching Funds (2 of 3)

Local Government or Other Source(s) of the Non-Federal Share of Computable Waiver Costs. Specify the source or

sources of the non-federal share of computable waiver costs that are not from state sources. Select One:

Not Applicable. There are no local government level sources of funds utilized as the non-federal share.

Applicable

Check each that applies:

Appropriation of Local Government Revenues.

Specify: (a) the local government entity or entities that have the authority to levy taxes or other revenues; (b) the

source(s) of revenue; and, (c) the mechanism that is used to transfer the funds to the Medicaid Agency or Fiscal

Agent, such as an Intergovernmental Transfer (IGT), including any matching arrangement (indicate any

intervening entities in the transfer process), and/or, indicate if funds are directly expended by local government

agencies as CPEs, as specified in Item I-2-c:

b.

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 110 of 118

06/24/2020

Other Local Government Level Source(s) of Funds.

Specify: (a) the source of funds; (b) the local government entity or agency receiving funds; and, (c) the

mechanism that is used to transfer the funds to the state Medicaid agency or fiscal agent, such as an

Intergovernmental Transfer (IGT), including any matching arrangement, and/or, indicate if funds are directly

expended by local government agencies as CPEs, as specified in Item I-2-c:

Appendix I: Financial Accountability

I-4: Non-Federal Matching Funds (3 of 3)

Information Concerning Certain Sources of Funds. Indicate whether any of the funds listed in Items I-4-a or I-4-b that

make up the non-federal share of computable waiver costs come from the following sources: (a) health care-related taxes

or fees; (b) provider-related donations; and/or, (c) federal funds. Select one:

None of the specified sources of funds contribute to the non-federal share of computable waiver costs

The following source(s) are used

Check each that applies:

Health care-related taxes or fees

Provider-related donations

Federal funds

For each source of funds indicated above, describe the source of the funds in detail:

c.

Appendix I: Financial Accountability

I-5: Exclusion of Medicaid Payment for Room and Board

Services Furnished in Residential Settings. Select one:

No services under this waiver are furnished in residential settings other than the private residence of the

individual.

As specified in Appendix C, the state furnishes waiver services in residential settings other than the personal home

of the individual.

a.

Method for Excluding the Cost of Room and Board Furnished in Residential Settings. The following describes the

methodology that the state uses to exclude Medicaid payment for room and board in residential settings:

Do not complete this item.

b.

Appendix I: Financial Accountability

I-6: Payment for Rent and Food Expenses of an Unrelated Live-In Caregiver

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 111 of 118

06/24/2020

Units Per User, and Avg. Cost/Unit fields for all the Waiver Service/Component items. Select Save and Calculate to

automatically calculate and populate the Component Costs and Total Costs fields. All fields in this table must be

completed in order to populate the Factor D fields in the J-1 Composite Overview table.

Waiver Year: Year 4

Waiver Service/

Component

Unit # Users Avg. Units Per User Avg. Cost/ Unit

Component

Cost

Total

Cost

Respite Total: 21868.00

Respite

15 minutes

7

390.50

8.00

21868.00

Transition Case

Management Total:

4860.00

Transition Case

Management

monthly

6

6.00

135.00

4860.00

Environmental Accessiblity

Adaptations Total:

35000.00

Environmental

Accessiblity Adaptations

per occurence

7

5.00

1000.00

35000.00

GRAND TOTAL: 61728.00

Total Estimated Unduplicated Participants: 20

Factor D (Divide total by number of participants): 3086.00

Average Length of Stay on the Waiver:

315

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (9 of 9)

Estimate of Factor D.

i. Non-Concurrent Waiver. Complete the following table for each waiver year. Enter data into the Unit, # Users, Avg.

Units Per User, and Avg. Cost/Unit fields for all the Waiver Service/Component items. Select Save and Calculate to

automatically calculate and populate the Component Costs and Total Costs fields. All fields in this table must be

completed in order to populate the Factor D fields in the J-1 Composite Overview table.

d.

Waiver Year: Year 5

Waiver Service/

Component

Unit # Users Avg. Units Per User Avg. Cost/ Unit

Component

Cost

Total

Cost

Respite Total: 24992.00

Respite

15 minutes

8

390.50

8.00

24992.00

Transition Case

Management Total:

5670.00

Transition Case

Management

monthly

7

6.00

135.00

5670.00

Environmental Accessiblity

Adaptations Total:

40000.00

Environmental

Accessiblity Adaptations

per occurence

8

5.00

1000.00

40000.00

GRAND TOTAL: 70662.00

Total Estimated Unduplicated Participants: 20

Factor D (Divide total by number of participants): 3533.00

Average Length of Stay on the Waiver:

315

Application for 1915(c) HCBS Waiver: FL.40166.R06.00 - Jul 01, 2020 Page 118 of 118

06/24/2020

Fill Online, Printable, Fillable, Blank Application for a 1915(c) Home and Community- Based (Florida) Form

Related forms

Fillable Application for a 1915(c) Home and Community- Based (Florida)

Fill Online, Printable, Fillable, Blank Application for a 1915(c) Home and Community- Based (Florida) Form

Related forms

First 20 documents completely FREE!