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


Participant-Direction Opportunities



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Participant-Direction Opportunities. Specify the participant-direction opportunities that are available in the waiver. Select one:




Participant – Employer Authority. As specified in Appendix E-2, Item a, the participant (or the participant’s representative) has decision-making authority over the workers who provide waiver services. Either the participant or an agency may function as the common law employer. Supports and protections are available for participants who exercise this authority.



Participant – Budget Authority. As specified in Appendix E-2, Item b, the participant (or the participant’s representative) has decision-making authority over a budget for waiver services. Supports and protections are available for participants who have authority over a budget.

X

Both Authorities. The waiver provides for both participant-direction opportunities as specified in Appendix E-2. Supports and protections are available for participants who exercise these authorities.

c. Availability of Participant Direction by Type of Living Arrangement. Check each that applies:

X

Participant direction opportunities are available to participants who live in their own personal home or the home of a family member.

X

Participant direction opportunities are available to individuals who reside in other living arrangements where services (regardless of funding source) are furnished to fewer than four persons unrelated to the proprietor.





The participant direction opportunities are available to persons in the following other living arrangements (specify):



d. Election of Participant-Direction. Election of participant-direction is subject to the following policy (select one):



Waiver is designed to support only individuals who want to direct their services.



The waiver is designed to afford every participant (or the participant’s representative) the opportunity to elect to direct waiver services. Alternate service delivery methods are available for participants who decide not to direct their services.

X

The waiver is designed to offer participants (or their representatives) the opportunity to direct some or all of their services, subject to the following criteria specified by the State. Alternate service delivery methods are available for participants who decide not to direct their services or do not meet the criteria. Specify the criteria:

The consumer must meet the eligibility requirements for this waiver and be enrolled in the waiver.

e. Information Furnished to Participant. Specify: (a) the information about the participant direction opportunities (e.g., the benefits of participant-direction, participant responsibilities, and potential liabilities) that is provided to the participant (or the participant’s representative) to inform decision-making concerning the election of participant direction; (b) the entity or entities responsible for furnishing this information; and, (c) how and when this information is provided.


When this option becomes available in a particular region of the state based on the progressive implementation plan, outreach and training will be done with consumers, family members, and case managers, Area Agencies on Aging, Child Health Specialty Clinics and Iowa Department of Human Services Service workers. The Department of Human Services and/or a designated representative will conduct the outreach and training. This training and outreach will include the benefits, responsibilities and liabilities of selecting the self-direction option. This training and outreach will be done on an ongoing basis as needed. A brochure about this option will also be developed that will include information about the benefits, responsibilities, and liabilities. This will be available at all the local Department of Human Services offices, the Department of Human Services website and will be distributed to other community agencies.

The case manager will also be required to discuss this option along with the benefits, responsibilities and liabilities at the time of the service plan development and/or any time the consumers needs change. This option will be very flexible, consumers can chose this option at anytime. Once giving information about this option, the consumer can immediately elect this option or continue or start with traditional services initially and then change their service plan at a later date. In addition, in order to give the consumer an opportunity to locate providers and supports, the service plan can reflect that traditional services will begin at start date of the service plan and the self directed services and support will begin at a later date. This will not require a change in the service plan. All self directed services and supports must start at a first of a month. Consumers can elect this option and then elect to go back to traditional services at anytime. The case manager will be responsible for informing the consumer of their rights and responsibilities for the self-direction option. All consumers will sign an informed consent contract and a risk agreement that will outline the responsibilities and risks of a self-direction option.



f. Participant Direction by a Representative. Specify the State’s policy concerning the direction of waiver services by a representative (select one):



The State does not provide for the direction of waiver services by a representative.

X

The State provides for the direction of waiver services by representatives. Specify the representatives who may direct waiver services: (check each that applies):




X

Waiver services may be directed by a legal representative of the participant.

X

Waiver services may be directed by a non-legal representative freely chosen by an adult participant. Specify policies that apply regarding the direction of waiver services by participant-appointed representatives, including safeguards to ensure that the representative works in the best interest of the individual:

The representative cannot be a paid provider of services and must be 18 years and older. The consumer must sign a consent form designating who they have chosen as their representative and what responsibilities that representative will have.


g. Participant-Directed Services. Specify the participant-direction opportunity (or opportunities) available for each waiver participant-directed service specified in Appendix C-3. (Check the opportunity or opportunities applicable for each service):


Participant-Directed Waiver Service

Employer

Authority

Budget

Authority

Independent Support Broker

X

X

Self Directed Personal Attendant Care Services

X

X

Community Support and Employment

X

X

Individual Directed goods and services

X

X















h. Financial Management Services. Except in certain circumstances, financial management services are mandatory and integral to participant direction. A governmental entity or another third-party entity must perform necessary financial transactions on behalf of the waiver participant. Select one:

X


Financial Management Services are furnished through a third party entity. (Complete item E-1-i). Specify whether governmental or private entities furnish these services. Check each that applies:



Governmental entities

X

Private entities



Financial Management Services are not furnished. Standard Medicaid payment mechanisms are used. Do not complete Item E-1-i.

i. Provision of Financial Management Services. Financial management services (FMS) may be furnished as a waiver service or as an administrative activity. Select one:

X

FMS are covered as the waiver service entitled

Financial Management Service

as specified in Appendix C-3.



FMS are provided as an administrative activity. Provide the following information:

i.


Types of Entities: Specify the types of entities that furnish FMS and the method of procuring these services:



ii.

Payment for FMS. Specify how FMS entities are compensated for the administrative activities that they perform:



iii.

Scope of FMS. Specify the scope of the supports that FMS entities provide (check each that applies):

Supports furnished when the participant is the common law employer of direct support workers:



Assists participant in verifying support worker citizenship status



Collects and processes timesheets of support workers



Processes payroll, withholding, filing and payment of applicable federal, state and local employment-related taxes and insurance



Other (specify):

Supports furnished when the participant exercises budget authority:




Maintains a separate account for each participant’s participant-directed budget



Tracks and reports on income, disbursements and balances of participant funds



Processes and pays invoices for goods and services approved in the service plan



Provides participant with periodic reports of expenditures and the status of the participant-directed budget



Other services and supports (specify):



Additional administrative functions/activities:



Executes and holds Medicaid provider agreements as authorized under a written agreement with the Medicaid agency



Receives and disburses funds for the payment of participant-directed services under an agreement with the Medicaid agency or operating agency


Provides other entities specified by the State with periodic reports of expenditures and the status of the participant-directed budget




Other (specify):



iv.

Oversight of FMS Entities. Specify the methods that are employed to (a) monitor and assess the performance of FMS entities, including ensuring the integrity of the financial transactions that they perform; (b) the entity (entities) responsible for this monitoring; and, (c) how frequently performance is assessed.



j. Information and Assistance in Support of Participant Direction. In addition to financial management services, participant direction is facilitated when information and assistance are available to support participants in managing their services. These supports may be furnished by one or more entities, provided that there is no duplication. Specify the payment authority (or authorities) under which these supports are furnished and, where required, provide the additional information requested (check each that applies):


Case Management Activity. Information and assistance in support of participant direction are furnished as an element of Medicaid case management services. Specify in detail the information and assistance that are furnished through case management for each participant direction opportunity under the waiver:




X

Waiver Service Coverage. Information and assistance in support of participant direction are provided through the waiver service coverage specified

in Appendix C-3 that is entitled:

Independent Support Broker



Administrative Activity. Information and assistance in support of participant direction are furnished as an administrative activity. Specify the types of entities that furnish these supports, how the supports are procured and compensated; describe in detail the supports that are furnished in conjunction with each participant direction opportunity under the waiver; and, the methods and frequency of assessing the performance of the entities that furnish these supports:



k. Independent Advocacy (select one).



Yes. Independent advocacy is available to participants who direct their services. Describe the nature of this independent advocacy and how participants may access this advocacy:




X

No. Arrangements have not been made for independent advocacy.


l. Voluntary Termination of Participant Direction. Describe how the State accommodates a participant who voluntarily terminates participant direction in order to receive services through an alternate service delivery method, including how the State assures continuity of services and participant health and welfare during the transition from participant direction:

Based on the consumer’s service plan, a consumer may be receiving both traditional waiver services as well as services and supports under an individual budget for self-direction. A consumer may voluntarily discontinue the self-direction option at anytime. The individual will continue to be eligible for services as specified in the service plan regardless if they choose the self-direction option or chose the traditional method. A new service plan will be developed if the consumer’s needs change or if they voluntary discontinue the self-direction option. The case manager will work with the consumer to assure that services are in place


m. Involuntary Termination of Participant Direction. Specify the circumstances when the State will involuntarily terminate a participant’s use of a participant direction opportunity and require the use of alternative service delivery methods, including how continuity of services and participant health and welfare is assured during the transition.

The Iowa Department of Human Services will terminate a consumer’s use of the self-direction option any time there is substantial evidence of Medicaid fraud or obvious misuse of funds. The case manager will develop a new service plan and assure alternative services are in place. There are no other circumstances when the state will involuntarily terminate a participant’s use of the self-direction option.



n. Goals for Participant-Direction. In the following table, provide the State’s goals for each year that the waiver is in effect for the unduplicated number of waiver participants who are expected to elect each applicable participant-direction opportunity. Annually, the State will report to CMS the number of participants who elect to direct their waiver services.

Table E-1-n




Employer Authority Only

Budget Authority Only or Budget Authority in Combination with Employer Authority

Waiver Year

Number of Participants

Number of Participants

Year 1







Year 2







Year 3




194

Year 4 (renewal only)




568

Year 5 (renewal only)





665



Appendix E-2: Opportunities for Participant-Direction

a. Participant – Employer Authority

i. Participant Employer Status. Specify the participant’s employer status under the waiver. Check each that applies:




Participant/Co-Employer. The participant (or the participant’s representative) functions as the co-employer (managing employer) of workers who provide waiver services. An agency is the common law employer of participant-selected staff and performs necessary payroll and human resources functions. Supports are available to assist the participant in conducting employer-related functions. Specify the types of agencies (a.k.a., “agencies with choice”) that serve as co-employers of participant-selected staff:




X

Participant/Common Law Employer. The participant (or the participant’s representative) is the common law employer of workers who provide waiver services. An IRS-Approved Fiscal/Employer Agent serves as the participant’s agent in conducting payroll and other employer responsibilities that are required by Federal and State law. Supports are available to assist the participant in conducting employer-related functions.

ii. Participant Decision Making Authority. The participant (or the participant’s representative) has decision making authority over workers who provide waiver services. Check the decision making authorities that participants exercise:


X

Recruit staff




Refer staff to agency for hiring (co-employer)

X

Select staff from worker registry

X

Hire staff




Refer staff to employer agent

X

Verify staff qualifications

X

Obtain criminal history and/or background investigation of staff. Specify how the costs of such investigations are compensated:

If a consumer chooses, the Financial Management Service will obtain a criminal history check and/or background investigation at no additional cost to the consumer


X

Specify additional staff qualifications based on participant needs and preferences so long as such qualifications are consistent with the qualifications specified in Appendix C-3.

X

Determine staff duties consistent with the service specifications in Appendix C-3.


X

Determine staff wages and benefits within the State’s limits

X

Schedule staff

X

Instruct and train staff in duties

X

Supervise staff

X

Evaluate staff performance

X

Verify time worked by staff and approve time sheets

X

Discharge staff or notify the co-employer of the need for substitute staff



Other (specify):



b. Participant – Budget Authority

i. Participant Decision Making Authority. When the participant has budget authority, indicate the decision-making authority that the participant may exercise over the budget. Check all that apply:

X

Reallocate funds among services included in the budget

X

Determine the amount paid for services within the State’s limits

X


Substitute service providers

X

Schedule the provision of services

X

Specify additional service provider qualifications consistent with the qualifications specified in Appendix C-3

X

Specify how services are provided, consistent with the service specifications contained in Appendix C-4

X

Identify service providers and refer for provider enrollment

X

Authorize payment for waiver goods and services

X

Review and approve provider invoices for services rendered



Other (specify):



ii. Participant-Directed Budget. Describe in detail the method(s) that are used to establish the amount of the participant-directed budget for waiver goods and services over which the participant has authority, including how the method makes use of reliable cost estimating information and is applied consistently to each participant. Information about these method(s) must be made publicly available.

Each consumer who chooses to self-direct their services will continue to have a traditional service plan developed that is based on the level of care assessment and need of the consumer. If a consumer has a need for the services available to be included in the individual budget (consumer directed attendant care, chore, home and vehicle modification, home delivered meals, home maker, basic respite, assistive devices, transportation and senior companion ) and they chose to self direct one or all of those available services, the individual budget amount is determined by what amount was authorized for those services on the traditional service plan.
Historically, consumers do not use 100% of their authorized services. To ensure that the state does not spend more than what is historically spent on the traditional side, each service authorized that the consumer chooses to self direct, will have a utilization adjustment factor applied to it. This utilization adjustment factor is determined by an analysis of what has historically been used for each service on an aggregate by consumers. The utilization adjustment factor will be analyzed, at a minimum, every six months and adjusted, as needed based historical use. This method will be used for all waiver consumers choosing this option
The following is an example of how individual budget is determined:
A consumer has a need for respite. On their traditional service plan they are authorized 10 units of respite at $20 a unit. That consumer decides that they would like to self-direct their respite services. The amount authorized is $200 in the traditional service plan. Historically only 80% of authorized respite is used. The utilization adjustment factor of 80% is applied. The consumer’s individual budget amount is $160

The total of monthly costs of all services (traditional and self directed services) cannot exceed the established aggregate monthly costs for level of care

Nursing Level of Care $1052 per month

Skilled Level of Care $2480 per month

This consumer is notified of the limits at the time their service plan of care is developed. Please Appendix C- 4 for more information.
The individual budget methodology will be stated in the Iowa Department of Human Services Administrative rules. In addition this information will be shared during all outreach and training meets held throughout the state for consumers, families, and other advocates that will be held on going.






iii. Informing Participant of Budget Amount. Describe the process by which the State informs each participant of the amount of the participant-directed budget and the procedures by which the participant may request an adjustment in the budget amount. In accordance with the procedures specified in Appendix F, the participant is offered the opportunity to request a Fair Hearing when the participant’s request for an adjustment to the budget is denied or the amount of the budget is reduced.

The consumer will be informed of their budget amount during the development of the service plan. The consumer can then make a final decision as to whether they want the self-direction option. If a consumer needs an adjustment to the budget, the consumer can request a review of the service plan. If there is a need that goes beyond the budget amount and/or the waiver service limit the consumer has the right to request an exception. . Exceptions to policy may be granted to the DHS rules. The decision is made by the Director of the Iowa Department of Human Services This process to request an exception is shared on the DHS website as well as with the consumer when they apply for waiver services. In addition any consumer has the right to appeal any decision made by the Department of Human Services and request an appeal hearing by an administrative law judge



iv. Participant Exercise of Budget Flexibility. Select one:

X

The participant has the authority to modify the services included in the participant-directed budget without prior approval. Specify how changes in the participant-directed budget are documented, including updating the service plan:

The consumer will actually have two budgets, a traditional service plan budget that actually determines the individual budget amount, and then the individual budget. Both will be tracked on Individual Service Information System. The individual budget will actually be subset from the traditional service plan. The consumer can modify services and adjust dollar amounts among line items in the individual budget without changing the service plan as long as it does not exceed the authorized budget amount. The Financial Management Service must receive all modifications to the individual budget and will monitor to assure the changes do not exceed the authorized budget amount. The Individual Support Broker and the Financial management service will both monitor to assure expenses are allowable expenses




Modifications to the participant-directed budget must be preceded by a change in the service plan.

v. Expenditure Safeguards. Describe the safeguards that have been established for preventing the premature depletion of the participant budget or address potential service delivery problems that may be associated with budget underutilization and the entity (or entities) responsible for ensuring the implementation of these safeguards:

Consumers authorized amount for the individual budget will be a monthly calculation. Consumer’s individualized budget will be planned by month. Consumers can adjust this at anytime within the authorized amount if it is not meeting their needs. The Independent Support Broker will also assist the consumer with developing their individual budget to assure that it meets their needs for the month. They also will monitor expenses. The Financial Management Service will also monitor the budget and will notify the Independent Support Broker and the consumer immediately if claims are inconsistent with the budgeted amount or if they consistently underutilized. When consumers chose this option they will sign a consent form that will explain their rights and responsibilities, including consequences for authorizing payments over the authorized budget amount






Appendix F: Participant-Rights

Appendix F-1: Opportunity to Request a Fair Hearing

a. Opportunity for 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.

b. Method 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. State laws, regulations, and policies referenced in the description are available through the operating or Medicaid agency.


The consumer is given an oral explanation of the appeals ( fair hearing )process during the application process by the Income Maintenance worker. Consumers are also given an oral explanation at the time of any contemplated action by the Department. Depending on the adverse action, this could be done by the Income Maintenance Worker, the Case Manager and/or Medical Services who performs the level of care determination. The consumer is also given written notification (by the Income Maintenance Worker, the case manager, and/or Medical Services, of the following at the time of application and at the time of any department actions affecting the claim for assistance:

  • The right to request a hearing

  • The procedure for requesting a hearing

  • The right to be represented by others at the hearing, unless otherwise specified by the stature or federal regulation

  • Provisions for payment of legal fees by the Department

  • How to have assistance continued while the appeal is pending

All Department of Human Services application forms, notices, pamphlets and brochures must contain information on the appeals process and the opportunity to request an appeal. This information is available at all of the local offices and on the Department Website. The process for filing an appeal can be found on all Notices of Decision issued by the Department. Procedures regarding the appeal hearing can be found on the Notice of Hearing. As stated in Iowa Administrative code, any person or group of persons may file an appeal with the department concerning any decision, made

The consumer shall be encouraged, but not required to make a written appeal on a standard form Appeal and Request a Hearing. If the consumer is unwilling to complete the form the appeal need to be in writing. The Iowa Department of Human Services shall advise each applicant and recipient of the right to appeal any adverse decision affecting the person’s status.

All notices are kept at all local Department of Human Services Offices. A copy may also be obtained on the Department of Human Services web site


c. Notice(s). Appendix #1 to Appendix F-2 contains the notice(s) that are used to offer individuals the opportunity to request a Fair Hearing.
Appendix F-2: Additional Dispute Resolution Process

a. 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:



The State operates an additional dispute resolution process (complete Item b)

X

Not applicable (do not complete Item b)

b. Description of Additional Dispute Resolution Process. Describe the State’s 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 through the operating or Medicaid agency.



Appendix F-3: State Grievance/Complaint System

a. Operation of Grievance/Complaint System. Select one:

X

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.



No. This Appendix does not apply (do not complete the remaining items)

b. Operational Responsibility. Specify the State agency that is responsible for the operation of the grievance/complaint system:

The Iowa Department of Human Services Medicaid Department is responsible for the operation. In addition the Department has a contract with Iowa State University that is responsible for the handling of complaints in regards to provision of services under this waiver




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