Geographic Limitation. A waiver of statewideness is requested in order to furnish services under this waiver only to individuals who reside in the following geographic areas or political subdivisions of the State. Specify the areas to which this waiver applies:
Limited Implementation of Participant-Direction. A waiver of statewideness is requested in order to make participant-direction of services as specified in Appendix E available only to individuals who reside in the following geographic areas or political subdivisions of the State. Participants who reside in these areas may elect to direct their services as provided by the State or receive the same services through the service delivery methods that are in effect elsewhere in the State. Specify the areas of the State affected by this waiver:
Iowa is requesting a waiver of state wideness to allow a participant directed option by geographic locations. Waiver participants in the specific geographic areas where participant direction is being made available will have the choice to direct their services or receive waiver services through the traditional service delivery methods that will continue to be available statewide. Iowa plans to have available the participant direction option statewide by March 1st 2007. Iowa will phase in participant direction by the Iowa Department of Human Services, Service Administrative Areas. Iowa is proposing the following phase in schedule:
July 1st 2006: Waterloo Service Area, which includes the following counties: Black Hawk, Bremer, Butler, Cerro Gordo Chickasaw, Floyd Franklin, Grundy, Hancock, Mitchell, Winnebago, Worth.
September 1st 2006: Ames Service Area, which includes the following counties: Calhoun, Hamilton, Hardin, Humboldt, Jasper, Marshall, Pocahontas, Poweshiek, Story, Tama, Webster, Wright.
October 1st 2006: Sioux City Service Area, which includes the following counties: Buena Vista, Clay, Cherokee, Emmet, Dickinson, IDA, Kossuth, Lyon, Obrien, Osceola, Plymouth, Sioux, Woodbury,
November 1st 2006: Council Bluffs Service Area, which includes the following counties: Audubon, Carroll, Cass, Crawford, Fremont, Greene, Guthrie, Harrison, Mills, Monona, Montgomery, Page, Pottawattamie, Sac, Shelby, Taylor
December 1st 2006: Dubuque Service Area, which includes the following counties: Allamakee, Buchanan, Clayton, Clinton, Delaware, Dubuque, Fayette, Howard, Jackson, Winneshiek.
January 1st 2007: Davenport Service Area: Cedar, Des Moines, Henry, Lee, Louisa, Muscatine, Scott.
February 1st 2007: Cedar Rapids Service Area: Appanoose, Benton, Davis, Iowa, Jefferson, Jones, Johnson, Keokuk, Linn, Mahaska, Monroe, Van Buren, Wapello, Washington
March 1st 2007: Des Moines Service Area: Adair, Adams, Boone, Clarke, Dallas, Decatur, Lucas, Madison, Marion, Polk, Ringgold, Union, Warren, Wayne.
In accordance with 42 CFR §441.302, the State provides the following assurances to CMS:
A. Health & Welfare:Necessary safeguards have been taken to protect the health and welfare of persons receiving services under this waiver. These safeguards include:
1. As specified in Appendix C, adequate standards for all types of providers that provide services under this waiver;
2. 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,
3. 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.
B. 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.
C. Evaluation of Need: The State 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 are specified in Appendix B.
D. Choice ofAlternatives: When an individual is determined to be likely to require the level of care specified for this waiver and is in the target group(s) specified in Appendix B, the individual (or, legal representative, if applicable) is:
1. Informed of any feasible alternatives under the waiver; and,
2. 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.
E. 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.
F. 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.
G. Institutionalization Absent Waiver: 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.
H. 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.
I. 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 Improvement Act of 2004 (IDEA) or the Rehabilitation Act of 1973; and, (2) furnished as part of expanded habilitation services.
J. 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) under age 21 when the State has not included the optional Medicaid benefit cited in 42 CFR § 440.160.
6. Additional Requirements
Note: Item I must be completed.
A. 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 amount, frequency and duration and the type of provider who 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.
B. 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/MR.
C. 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
D. Access to Services. The State does not limit or restrict participant access to specific waiver services except as provided in Appendix C.
E. Free Choice of Provider. In accordance with 42 CFR §431.51, 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)(4) or another section of the Act.
F.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.
G. 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 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.
H. Quality Management. 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 Management Strategy specified in Appendix H.
I. Public Input. Describe how the State secures public input into the development of the waiver:
Iowa receives public input from various committees and organizations. There is a Senior Living coordinating unit that meets four times a year to provide input to the elderly waiver services. Specifically for the implementation of participant directed services, a Self Direction Sub Committee has been established and meets monthly. Both the Senior Living Coordinating Unit and the Self Direction Sub Committee have a variety of stakeholder participants from consumers and families, providers, case managers, and other state departments. In addition, Regional meetings are held on a quarterly basis around the state for stakeholders to ask questions and provide input.
J.Notice to Tribal Governments. The State assures that it has notified in writing all federally-recognized Tribal Governments maintaining 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 to at least 60 days before the anticipated submission date per Presidential Executive Order 13175 of November 6, 2000. Evidence of the applicable notice is available through the Medicaid Agency.
K.Limited English Proficiency Persons. The State assures that it provides meaningful access to waiver services by Limited English Proficiency 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 Proficiency persons.
7. Contact Person(s)
A. The State Medicaid Agency representative with whom CMS should communicate regarding the waiver is:
Blovela@dhs.state.ia.us or email@example.com
B. If applicable, the State Operating Agency representative with whom CMS should communicate regarding the waiver is:
8. Authorizing Signature
This document, together with Appendices A through J and any attachments, 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 when requested by CMS through the Medicaid Agency or, if applicable, from the waiver operating agency specified in Appendix A. Any proposed changes to the waiver will be submitted in writing by the State 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 waiver and will continuously operate the waiver in accordance with the assurances specified in Section V and the additional requirements specified in Section VI of the request.
State Medicaid Director or Designee
Iowa Department of Human Services
Iowa Medicaid Enterprise
100 Army Post RD
Attachment #1: Transition Plan to New Waiver
Note: Attachment #1 is completed only when a state proposes a new waiver to replace an existing waiver program.
Specify the transition plan from the current waiver to the new replacement waiver:
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.
Bureau of Long Term Care
, another division/unit within
the State Medicaid agency that is separate from the Medical Assistance Unit. Do not complete item A-2.
The waiver is operated by
a separate agency of the State that is not a division/unit of the Medicaid agency. In accordance with 42 CFR §431.10, the Medicaid agency exercises administrative discretion in the administration and supervision of the 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. Complete item A-2.
2. Medicaid Agency Oversight of Operating Agency Performance. When the waiver is not operated by the Medicaid agency, specify the methods that the Medicaid agency uses and the frequency of their use to ensure that the operating agency performs its assigned waiver operational and administrative functions in accordance with waiver requirements:
3. Use of Contracted Entities. Specify whether contracted entities perform waiver operational and administrative functions on behalf of the Medicaid agency or the waiver operating agency (if different than the Medicaid agency) (select one):
Contracted entities perform waiver operational and administrative functions on behalf of the Medicaid agency and/or waiver operating agency.
Contracted entities do not perform waiver operational and administrative functions on behalf of the Medicaid agency and/or the waiver operating agency.
4. Role of Local/Regional Non-State Entities. Indicate whether local or regional non-state entities perform waiver operational and administrative functions and specify the type of entity (check each that applies):
Local/Regional non-state public agencies conduct waiver operational and administrative functions at the local or regional level. There is an interagency agreement or memorandum of understanding between the Medicaid agency and/or the operating agency (when authorized by the Medicaid agency) and each local/regional non-state agency that sets forth the responsibilities and performance requirements of the local/regional agency. The interagency agreement or memorandum of understanding is available through the Medicaid agency or the operating agency (if applicable). 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 through the Medicaid agency or the operating agency (if applicable). Specify the nature of these entities and complete items A-5 and A-6:
Not applicable – All waiver operational and administrative functions are performed by a state agency. Do not complete items A-5 and A-6.
5. Responsibility for Assessment of Performance of Local/Regional Non-State Entities. Specify the State agency that is responsible for assessing the performance of non-state entities that conduct waiver operational and administrative functions:
The Iowa Medicaid Enterprise, Medicaid Policy Staff, through the Department of Human Services is responsible for oversight of the contracting agencies
6. Assessment Methods. Describe the methods that the State uses and the frequency of their use to assess the performance of non-state entities to ensure that they perform assigned waiver operational and administrative functions in accordance with waiver requirements:
All contracted entities are assessed through their performance-based contracts. The contracted agencies are required to present at a weekly meeting to the Medicaid Policy Staff their performance on their contract standards. All contracted entities and Medicaid Policy staff are located at the same site. In addition contracted agencies are required to complete a full quarterly report on their performance which includes information obtained from satisfaction surveys.
7. 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 (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 conducting the function.
Other State Operating Agency
Local Non-State Entity
Disseminate information concerning the waiver to potential enrollees
Assist individuals in waiver enrollment
Manage waiver enrollment against approved limits
Monitor waiver expenditures against approved levels
Conduct level of care evaluation activities
Review participant service plans to ensure that waiver requirements are met
Conduct training and technical assistance concerning waiver requirements
Please note that ultimately it is the Medicaid agency that has overall responsibility for all of the functions. Some of the functions are performed by contracting agencies. In regards to training, technical assistance, recruitment and disseminating information, this is done by both the Medicaid agency and contracted agencies throughout conducting regular day to day business
Appendix B: Participant Access and Eligibility
Appendix B-1: Specification of the Waiver Target Group(s)
a. Target Group(s). Under the waiver of Section 1902(a)(10)(B) of the Act, the State limits waiver services to a group or subgroups of individuals. In accordance with 42 CFR §441.301(b)(6), select one waiver target group, check each subgroup in the selected target group that may receive services under the waiver, and specify the minimum and maximum (if any) age of individuals served in each subgroup.
Maximum Age Limit: Through age –
No Maximum Age Limit
Aged or Disabled, or Both
Aged (age 65 and older)
Disabled (Physical) (under age 65)
Disabled (Other) (under age 65)
Specific Aged/Disabled Subgroup
Mental Retardation or Developmental Disability, or Both
Mental Illness (age 18 and older)
Serious Emotional Disturbance (under age 18)
Additional Criteria. The State further specifies its target group(s) as follows:
Certified as being in need of nursing or skill level of care
c. Transition of Individuals Affected by Maximum Age Limitation. When there is a maximum age limitation on individuals who may be served in the waiver, describe the transition planning procedures for 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):
Appendix B-2: Individual Cost Limit
a. Individual Cost Limit. The following individual cost limit applies when determining whether to deny home and community-based services or entrance to the waiver to an otherwise eligible individual (select one):
No Cost Limit. The State does not apply an individual cost limit. Do not complete item B-2-b or item B-2-c.
Cost Limit in Excess of Institutional Costs. The State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed the cost of a level of care specified for the waiver by an amount specified by the State. Complete items B-2-b and B-2-c. The limit specified by the State is (select one):
%, a level higher than 100% of the institutional average
The total costs of elderly services cannot exceed the following:
Nursing Level of Care $1052 per month
Skilled Level of Care $2480.00 per month
Institutional Cost Limit. Pursuant to 42 CFR 441.301(a)(3), the State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed the 100% of the cost of the level of care specified for the waiver. Complete items B-2-b and B-2-c.
Cost Limit Lower Than Institutional Costs. The State refuses entrance to the waiver to any otherwise qualified individual when the State reasonably expects that the cost of home and community-based services furnished to that individual would exceed the following amount specified by the State that is less than the cost of a level of care specified for the waiver. Specify the basis of the limit, including evidence that limit is sufficient to assure the health and welfare. Of waiver participants. Complete items B-2-b and B-2-c. :
The cost limit specified by the State is (select one):
The following dollar amount: $
The dollar amount (select one):
Is adjusted each year that the waiver is in effect by applying the following formula:
May be adjusted during the period the waiver is in effect. The State will submit a waiver amendment to CMS to adjust the dollar amount.
The following percentage that is less than 100% of the institutional average:
Other – Specify:
b. Method of Implementation of Cost Limit. When an individual cost limit is specified in item B-2-a, specify the procedures that are followed to determine in advance of waiver entrance that the individual’s health and welfare can be assured within the cost limit:
An interdisciplinary team consisting of the consumer, the case manager providers, and other persons the consumer chooses develop a service plan of care that identifies the consumers needs as well as the availability and appropriateness of services. This plan assures health and welfare. Consumers may request an exception to policy if there is a need outside of the cost limit. Exceptions to policy may be granted to the DHS rules. This information 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
c. Participant Safeguards. When the State specifies an individual cost limit in item B-2-a and there is a change in the participant’s condition or circumstances that requires the provision of services that exceed the cost limit in order to assure the participant’s health and welfare, the State provides the following safeguards to avoid an adverse impact on the participant (check each that applies):
The participant is referred for services in another waiver that can accommodate the individual’s needs.
Additional services in excess of the individual cost limit may be authorized. Specify the procedures for authorizing additional services, including the amount that may be authorized:
If additional services in excess of the individual cost limit are needed, The director of the Department may grant exceptions to the Department’s rules in individual cases upon the director’s own initiative or upon request. Any person may file a request for exception with the Department. Exceptions are granted at the complete discretion of the director after considerations of all relevant factors. These include but are not limited to:
The need of the person or entity directly affected for the exception. (Exceptions are granted only in cases of extreme need.)
Whether there are exceptional circumstances justifying an exception to the general rule applicable in otherwise similar circumstances.
Whether granting the exception would result in net savings to the state or promote efficiency in the administration of programs or service delivery. (Net savings or efficiency makes an exception more likely.)
In the case of services, assistance, or grants, whether other possible sources have been exhausted. (Exceptions are not generally granted if other sources are available.)
The cost of the exception to the state and the availability of funds in the Department’s budget. The amount authorized cannot exceed the availability of funds in the Department’s Budget.
Other safeguard(s) (specify):
Appendix B-3: Number of Individuals Served
a. Unduplicated Number of Participants. The following table specifies the maximum number of unduplicated participants who are served in each year that the waiver is in effect. The State will submit a waiver amendment to CMS to modify the number of participants specified for any year(s), including when a modification is necessary due to legislative appropriation or other reason. The number of unduplicated participants specified in this table is basis for the cost-neutrality calculations in
Appendix J: We do not anticipate any changes from these numbers that were submitting on our renewal application
Year 4 (renewal only)
Year 5 (renewal only)
b. Limitation on the Number of Participants Served at Any Point in Time. Consistent with the unduplicated number of participants specified in Item B-3-a, the State may limit to a lesser number the number of participants who will be served at any point in time during a waiver year. Select whether the State limits the number of participants in this way: (select one):
The State does not limit the number of participants that it serves at any point in time during a waiver year.
The State limits the number of participants that it serves at any point in time during a waiver year. The limit that applies to each year of the waiver period is specified in the following table:
Maximum Number of Participants Served At Any Point During the Year
Year 4 (renewal only)
Year 5 (renewal only)
c. Reserved Waiver Participant Capacity. The State may reserve a portion of the participant capacity of the waiver for specified purposes (e.g., provide for the community transition of institutionalized persons or furnish waiver services to individuals experiencing a crisis) subject to CMS review and approval. The State (select one):
Does not reserve capacity.
The State reserves capacity for the following purpose(s). For each purpose, describe how the amount of reserved capacity was determined:
The capacity that the State reserves in each waiver year is specified in the following table:
Year 4 (renewal only)
Year 5 (renewal only)
d. 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 Appendix J. This schedule constitutes an intra-year limitation on the number of participants who are served in the waiver.
e. Allocation of Waiver Capacity.Select one:
Waiver capacity is allocated on a statewide basis.
Waiver capacity is allocated to local non-state entities. Specify: (a) the entities to which waiver capacity is allocated; (b) the methodology that is employed to allocate capacity; and, (c) policies for the reallocation of unused capacity among local non-state entities:
f. Selection of Entrants to the Waiver. Specify the policies that apply to the selection of individuals for entrance to the waiver:
Individuals are accepted into the waiver on a first come basis based on the date of application.