Application for a §1915 (c) hcbs waiver Submitted by

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Application for a §1915(c) HCBS Waiver

Draft Application Version 3.2 for Use by States – June 2005

Application for a §1915 (c) HCBS Waiver
Submitted by:

Submission Date:

March 29th

CMS Receipt Date (CMS Use)

Provide a brief one-two sentence description of the request (e.g., renewal of waiver, request for new waiver, amendment):

Brief Abstract:

This is a request to amend our current Elderly waiver to add a self direction option and case management service

Application for a §1915(c) Home and Community-Based Services Waiver


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 waiver’s 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.

HCBS Quality Framework


Desired Outcome

Participant Access

Individuals have access to home and community-based services and supports in their communities.

Participant-Centered Service Planning and Delivery

Services and supports are planned and effectively implemented in accordance with each participant’s unique needs, expressed preferences and decisions concerning his/her life in the community.

Provider Capacity and Capabilities

There are sufficient HCBS providers and they possess and demonstrate the capability to effectively serve participants.

Participant Safeguards

Participants are safe and secure in their homes and communities, taking into account their informed and expressed choices.

Participant Rights and Responsibilities

Participants receive support to exercise their rights and in accepting personal responsibilities.

Participant Outcomes and Satisfaction

Participants are satisfied with their services and achieve desired outcomes.

System Performance

The system supports participants efficiently and effectively and constantly strives to improve quality.
The waiver application is based on the HCBS Quality Framework. The Framework focuses on seven broad, participant-centered desired outcomes for the delivery of waiver services, including assuring participant health and welfare. It also stresses the importance of respecting the preferences and autonomy of waiver participants. The Framework identifies the es­sential elements for assuring and improving the quality of waiver services: design, dis­covery, remediation and improvement. The State has flexibility in developing and implementing a Quality Man­agement Strategy that promotes the achievement of the desired outcomes expressed in the Quality Framework.

1. Request Information


The State of


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).


Program Title (optional):


C. Type of Request (select only one): Waiver amendment

New Waiver (3 Years)

CMS-Assigned Waiver Number (CMS Use):

New Waiver (3 Years) to Replace Waiver #

CMS-Assigned Waiver Number (CMS Use):

Attachment #1 contains the transition plan to the new waiver.

Renewal (5 Years) of Waiver #

D. Type of Waiver (select only one):

Model Waiver. In accordance with 42 CFR §441.305(b), the State assures that no more than 200 individuals will be served in this waiver at any one time.


Regular Waiver, as provided in 42 CFR §441.305(a)


Proposed Effective Date:

July 1st 2006


Approved Effective Date (CMS Use):

F. Level(s) of Care. This waiver is requested in order to provide home and community-based waiver services to individuals who, but for the provision of such services, would require the following level(s) of care, the costs of which would be reimbursed under the approved Medicaid State plan (check each that applies):

Hospital (select applicable level of care)

Hospital as defined in 42 CFR §440.10. If applicable, specify whether the State additionally limits the waiver to subcategories of the hospital level of care:

Inpatient psychiatric facility for individuals under age 21 as provided in 42 CFR § 440.160


Nursing Facility (select applicable level of care)

As defined in 42 CFR §440.40 and 42 CFR §440.155. If applicable, specify whether the State additionally limits the waiver to subcategories of the nursing facility level of care:

Institution for Mental Disease for persons with mental illnesses aged 65 and older as provided in 42 CFR §440.140

Intermediate Care Facility for the Mentally Retarded (ICF/MR) (as defined in
42 CFR §440.150). If applicable, specify whether the State additionally limits the waiver to subcategories of the ICF/MR facility level of care:

G. Concurrent Operation with Other Programs. This waiver operates concurrently with another program (or programs) approved under the following authorities (check the applicable authority or authorities):

Services furnished under the provisions of §1915(a) of the Act and described in Appendix I

Waiver(s) authorized under §1915(b) of the Act. Specify the program:

Specify the §1915(b) authorities under which this program operates (check each that applies):

§1915(b)(1) (mandated enrollment to managed care)

§1915(b)(3) (employ cost savings to furnish additional services)

§1915(b)(2) (central broker)

§1915(b)(4) (limit number of providers)

A program authorized under §1115 of the Act. Specify the program:


Not applicable

2. Brief Program Description

Brief Program 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.

The purpose of the Medicaid Home and Community Based Services Elderly waiver is to provide service funding and individualized supports to maintain eligible consumers in their own homes or communities who would otherwise require care in a medical institution. The goal of this waiver is provide alternatives to institutional services. Our objective is to provide waiver services to approximately 1000 new consumers each year. The Iowa Department of Human Services (DHS) Iowa Medicaid Enterprise is the single state agency responsible for the oversight of Medicaid. Individuals access the Elderly waiver services by applying at their local DHS office. If the individual is deemed eligible they will be chose a case manager. The services that are considered necessary and appropriate for the consumer will be determined through a person centered planning process with assistance from an interdisciplinary team consisting of the consumer, the case manager, service providers, and the Area Aging on Aging and others the participant chooses. The individual will have the option to use both traditional delivered services and self-directed services. The following services are available: Adult Day Care, Assistive devices, Chore, Consumer Directed Attendant Care, Home and Vehicle Modification, Home-Delivered Meals, Home Health Aide, Homemaker, Mental Health Outreach, Nursing, Nutritional Counseling, Personal Emergency Response, Respite, Senior Companion and Transportation. Financial Management Services and Independent Support brokerage services, Self Directed Personal Care, Individual Directed Goods and Services and Self Directed Community and Employment Supports will be available for the individuals who chose to self-direct their services. The case manager completes the assessment The assessment is used to determine the level care which is done by Medical services through the Iowa Medicaid Enterprise The consumers’ service plans are approved by the case manager and the Department of Human Service

3. Components of the Waiver Request

The waiver application consists of the following components. Note: Item E must be completed.

A. Waiver Administration and Operation. Appendix A specifies the administrative and operational structure of this waiver.

B. 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.

C. Participant Services. Appendix C specifies the home and community-based waiver services that are furnished through the waiver, including applicable limitations on such services.

D. Participant-Centered Service Planning and Delivery. Appendix D specifies the procedures and methods that the State uses to develop, implement and monitor the participant-centered service plan (of care).

E. Participant-Direction of Services. When the State provides for participant direction of services, Appendix E specifies the participant direction opportunities that are offered in the waiver and the supports that are available to participants who direct their services. (Select one):


The waiver provides for participant direction of services. Appendix E is required.

Not applicable. The waiver does not provide for participant direction of services.
Appendix E is not included.

F. Participant Rights. Appendix F specifies how the State informs participants of their Medicaid Fair Hearing rights and other procedures to address participant grievances and complaints.

G. Participant Safeguards. Appendix G describes the safeguards that the State has established to assure the health and welfare of waiver participants in specified areas.

H. Quality Management Strategy. Appendix H contains the Quality Management Strategy for this waiver.

I. Financial Accountability. Appendix I describes the methods by which the State makes payments for waiver services, ensures the integrity of these payments, and complies with applicable federal requirements concerning payments and federal financial participation.

J. Cost-Neutrality Demonstration. Appendix J contains the State’s demonstration that the waiver is cost-neutral.
4. Waiver(s) Requested

A. Comparability. The State requests a waiver of the requirements contained in §1902(a)(10)(B) of the Act in order to provide the services specified in Appendix C that are not otherwise available under the approved Medicaid State plan to individuals who: (a) require the level(s) of care specified in item I.F and (b) meet the target group criteria specified in Appendix B.

B. Income and Resources for the Medically Needy. Indicate whether the State requests a waiver of §1902(a)(10)(C)(i)(III) of the Act in order to use institutional income and resource rules for the medically needy (select one):




Not applicable

C. Statewideness. Indicate whether the State requests a waiver of the statewideness requirements in §1902(a)(1) of the Act (select one):


Yes (complete remainder of item)


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