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



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iv. State Oversight Responsibility. Specify the State agency (or agencies) responsible for monitoring the performance of waiver providers in the administration of medications to waiver participants and how monitoring is performed and its frequency.

To be enrolled as a respite provider, the agency must supply to provider enrollment their policy and procedures for Medication Management. Providers also must submit any major incidents of medication errors to the HCBS Specialists for the Iowa Department of Human Services. The Quality Assurance Sub committee reviews any trends of medication errors. In addition the provider must track and trend any minor incidents. Department of Inspections and Appeals is responsible for oversight of Home Health Agencies.






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Appendix H: Quality Management Strategy

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

Quality Management 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. A Quality Management Strategy is explicitly describes the processes of discovery, remediation and improvement; the frequency of those processes; the source and types of information gathered, analyzed and utilized to measure performance; and key roles and responsibilities for managing quality.

CMS recognizes that a state’s waiver Quality Management 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 the waiver assurances set forth in 42 CFR §441.301 and §441.302.

It may be more efficient and effective for a Quality Management 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 services that are addressed in the Quality Management Strategy.

Quality management is dynamic and the Quality Management Strategy may, and probably will, change over time. Modifications or updates to the Quality Management Strategy shall be submitted to CMS in conjunction with the annual report required under the provisions of 42 CFR §441.302(h) and at the time of waiver renewal.


Quality Management Strategy: Minimum Components

The Quality Management Strategy that will be in effect during the period of the waiver is included as Attachment #1 to Appendix H. The Quality Management Strategy should be no more than ten-pages in length. It may reference other documents that provide additional supporting information about specific elements of the Quality Management Strategy. Other documents that are cited must be available to CMS through the Medicaid agency or the operating agency (if appropriate).



  1. The Quality Management Strategy must describe how the state will determine that each waiver assurance is met. For each waiver assurance, this description must include:

  • Activities or processes related to discovery, i.e. monitoring and recording the findings. Descriptions of monitoring/oversight activities that occur at the individual and provider level of service delivery are provided in the application in Appendices B, C, D, G, and I. These monitoring activities provide a foundation for Quality Management by generating information that can be aggregated and analyzed to measure the overall system performance. The description of the Quality Management Strategy should not repeat the descriptions that are addressed in other parts of the waiver application;

  • The roles and responsibilities of the parties involved in measuring performance and making improvements must be specified. Such parties include (but are not limited to) the waiver administrative entities identified in Appendix A, waiver participants individuals, advocates, and service providers;

  • The entities or individuals responsible for conducting the discovery/monitoring processes;

  • The types of information used to measure performance; and,

  • The frequency with which performance is measured.


  1. The Quality Management Strategy must describe roles and responsibilities of the parties involved in measuring performance and making improvements must be specified. Such parties include (but are not limited to) the waiver administrative entities identified in Appendix A, waiver participants, advocates, and service providers.

Roles and responsibilities may be described comprehensively; it is not necessary to describe roles and responsibilities assurance by assurance. This description of roles and responsibilities may be combined with the description of the processes employed to review findings, establish priorities and develop strategies for remediation and improvement as specified in #3 below.

  1. Quality Management Strategy must describe the processes employed to review findings from its discovery activities, to establish priorities and to develop strategies for remediation and improvement. The description of these process(es) employed to review findings, establish priorities and develop strategies for remediation and improvement may be combined with the description of roles and responsibilities as specified in # 2 above.
  2. The Quality Management Strategy must describe how the State compiles quality management information and the frequency with which the State communicates this information (in report or other forms) to waiver participants, families, waiver service providers, other interested parties, and the public. Quality management reports may be designed to focus on specific areas of concern; may be related to a specific location, type of service or subgroup of participants; may be designed as administrative management reports; and/or may be developed to inform stakeholders and the public.


  3. The Quality Management Strategy must include periodic evaluation of and revision to the Quality Management Strategy. Include a description of the process and frequency for evaluating and updating the Quality Management Strategy.

If the State's Quality Management 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 Management Strategy, including the specific tasks that the State plans to undertake during the period that 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 Management Strategy spans more than one waiver and/or other types of long-term services under the Medicaid State plan, specify the control numbers for the other waiver programs and identify the other long-term services that are addressed in the Quality Management Strategy.



Attachment #1 to Appendix H

The Quality Management Strategy for the waiver is:


Please see attachment H #1 and H #2






Appendix I: Financial Accountability



APPENDIX I-1: Financial Integrity and Accountability

Financial Integrity. Describe the methods that are employed to ensure the integrity of payments made for waiver services, including: (a) requirements concerning the independent audit of provider agencies; (b) the financial audit program that is conducted by the state to ensure the integrity of provider billings for Medicaid payment of waiver services, including the methods, scope and frequency of audits that are conducted; and, (c) the agency (or agencies) responsible for conducting the financial audit program. State laws, regulations, and policies referenced in the description are available through the Medicaid agency or the other waiver operating agency (if applicable).

The Iowa Department of Human Services has developed a computer program, named the “Individualized Services Information System” or “ISIS,” to support the waiver programs. The purpose of ISIS is to assist workers in these programs in processing and tracking requests, starting with an initial entry from the ABC system through approval or denial. Upon approval, participants will use ISIS to provide, the Iowa Medicaid Enterprise (formally called the fiscal agent) with information and authority to make payments to or on behalf of a consumer. The consumer is tracked in ISIS until that consumer is no longer accessing a waiver program. There are certain points in the ISIS process that will require contact with designated DHS central office personnel and other outside entities. These contacts must be made in order for the ISIS process to proceed. These contacts may include the Medicaid arbitrator, HCBS waiver program managers, contacts for HCBS waiver slots and waiting lists, the Iowa Medicaid Enterprise and Medical Services through the Iowa Medicaid Enterprise


A case normally starts with an income maintenance (IM) worker entering information into

the Department’s Automated Benefit Calculation (ABC) system. The ABC system passes

pertinent information about the case to ISIS. Then ISIS identifies a key task (called a “milestone”) for the IM worker who entered the original data into ABC. This key task is the first in a series of milestones for actions by service workers, case managers, Child Health Specialty Clinic workers, central point of coordination administrators, and many others. These milestones form a workflow taking a request for a facility or waiver program to denial or final approval.

In addition, the Department of Human Services Bureau of Purchased Services performs both a financial and performance audits of Medicaid Providers. The billing audit is to ensure:


  • HCBS providers appropriately and accurately document the provision of services so that claims paid by the Department are eligible for reimbursement

  • To limit the risk of providers having to refund payments to the Department because they have submitted ineligible claims

  • To limit the risk of the Department losing or having to return matching federal funds because of having paid ineligible claims

At the end of each state fiscal year, an analysis of payments, recoupments and other risk related factors will be used to select and prioritize providers for billing audits to be conducted during the next auditing year (from October 1 to September 30).


The Bureau of Purchased Services will analyze payments, recoupments and other risk related factors from the previous State fiscal year and create a prioritized list of providers by program selected for audit in September of each calendar year.

Note: This selection process is only intended to be used as a tool by the Department to better focus its risk management efforts and resources. It is not meant to, nor does it limit the right of the Department to audit any provider at anytime at the Department’s sole discretion.

Selection Criteria
The primary factors that will be used by the Bureau to select and prioritize providers for audit are:

  • Total payments to the agency in the previous State fiscal year.

  • Payments for each program to the agency in the previous State fiscal year.

  • Recoupments from the agency during the previous State fiscal year.

  • The ranking of each program offered by an agency compared to the same program provided by other agencies.

  • Possible problems:
    • Issues identified in the provider’s cost report that raise questions about a provider’s financial stability, appropriate cost allocation, evidence of undisclosed or inappropriate sub-contractual or related party relationships, or compliance with HCBS requirements.


    • Issues identified by department staff that raise questions about a providers financial stability or programmatic viability or compliance with HCBS requirements.

    • Issues identified by other government agencies, by other provider agencies, or the public that raise questions about a provider’s stability or programmatic viability or compliance with HCBS requirements.

    • Providers that are completing a Provider Improvement Plan (PIP) as a result of a previous billing audit or certification review.

    • Providers that were sanctioned during the previous state fiscal year.

    • Providers suspected of fraud or falsifying documentation.

Other factors that will be used by the Bureau to select and prioritize providers for audit are:

  • Length of time since last billing audit.

    • All providers will be audited at least once every 5 years and more often if resources allow.

Exception: Providers who receive only minimal HCBS payments, will not be prioritized for audit because of length of time since their last billing audit.

  • Upon termination if a provider has not been audited for 2 or more years and they have received payments in excess of $100,000 in the time period since their last billing audit.

  • Providers experiencing high growth or high staff turnover.

  • Providers experiencing a large increase in HCBS payments or experiencing a large increase in the number of sites from which they are providing services.

  • Providers who are experiencing rapid staff turnover or who are adding high numbers of either the staff who provide and document service delivery or the staff who train and/or supervise these staff.
  • A combination of high growth and a high number of new staff.


  • In addition, a few providers not otherwise selected may be selected at random for audit.

The Bureau will analyze the above factors at the end of each fiscal year, create a prioritized list of providers by program selected for audit in September of each calendar year and provide this list to the Management Analysts.

The Bureau of Purchased Services has a policy in place on the procedure for reporting non compliance to the provider and to the Bureau of Long Term Care.
In cases of suspected Medicaid Fraud, The Iowa Department of Inspections and Appeals is responsible for investigating.



APPENDIX I-2: Rates, Billing and Claims

a. Rate Determination Methods. In two pages or less, describe the methods that are employed to establish provider payment rates for waiver services and the entity or entities that are responsible for rate determination. Indicate any opportunity for public comment in the process. If different methods are employed for various types of services, the description may group services where the same method is employed.

Adult Day, Personal Emergency Response, Homemakers, Home Delivered Meals, Home and Vehicle Modification, Nutritional Counseling, Chore, and mental health outreach providers, transportation, senior companion and assistive devices are reimbursed by Fee Schedules. Fee schedules are fees for the various procedures involved that are determined by the department with advice and consultation from the appropriate professional group. The fees are intended to reflect the amount of resources involved in each procedure. Individual adjustments will be made periodically to correct any inequality or to add new procedures or eliminate or modify others. If product cost is involved in addition to service, reimbursement is based either on fixed fee wholesale costs, or an actual acquisition cost of the product to the provider, or product costs in included as part of the fee schedule. Nursing services are a fee schedule that is determined by Medicare

Respite, when provided by a home health agencies are paid for the nursing services rate. When a home care agency, non-facility provider or camps provide respite, retrospectively limited prospective rates are used. These providers are reimbursed on the basis of a rate for a unit of services calculated prospectively for each participating provider based on projected or historical costs of operation, subject to the maximums listed in administrative rules and to the retrospective adjustment based on the actual, current costs of operation so as not to exceed reasonable and proper costs by more than 2.5 percent. Respite when provided by facilities are reimbursed by fee schedules.
Consumer Directed Attendant Care Services are reimbursed based on the agreement of the consumer and the provider. .
For services that the consumer self directs (self directed personal attendant care, Individualized directed goods and services, and self directed community support and employment) the consumer negotiates a rate for the entity providing services, goods and supports. Except for the Financial Management Service and Independent Support Broker service which will be negotiated by the Iowa Medicaid Enterprise
The Iowa Medicaid Enterprise, through the provider auditing and rate setting is responsible for rate setting. All provider rates are part of Iowa Administrative Rules and are subject to public comment


b. Flow of Billings. Describe the flow of billings for waiver services, specifying whether provider billings flow directly from providers to the State’s claims payment system or whether billings are routed through other intermediary entities. If billings flow through other intermediary entities, specify the entities:




  • Providers shall submit claims on a monthly basis for waiver services provided to each individual served by the provider agency.

  • Providers may submit manual or electronic claim forms:

    • Manual claims shall be directed to the Iowa Medicaid Enterprise (IME)/Provider Services Unit.

    • Electronic claims shall utilize the HIPAA compliant software, PC-ACE Pro32 and shall be processed by the Iowa Medicaid Enterprise/Provider Services Unit.

  • Providers shall submit a claim form that accurately reflects the following:

    • The provider’s approved Medicaid waiver provider number

    • The appropriate waiver procedure code(s) that correspond to the waiver services authorized in the service worker or case manager’s service plan (case plan).

    • The appropriate waiver service unit(s) and fee that corresponds to the service worker or case manager’s service plan (case plan).

  • The IME/Provider Services Unit issues provider payments on the second and fourth Mondays of each month.

  • The ISIS system edits insure that payment will not be made for services that are not included in an approved service plan (plan of care). Any change to ISIS data generates a new program request. The program request culminates in a final milestone that verifies an approved service plan has been entered into ISIS. ISIS data is updated daily into MMIS.


c. Certifying Public Expenditures (select one):


Yes. Public agencies directly expend funds for part or all of the cost of waiver services and certify their public expenditures (CPE) in lieu of billing that amount to Medicaid (check each that applies):







Certified Public Expenditures (CPE) of State Public Agencies. Specify: (a) the 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 Non-State Public Agencies. Specify: (a) the non-State public agencies that incur certify 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.)



X

No. Public agencies do not certify expenditures for waiver services.

d. 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 ISIS system provides for edits to make sure that all claims are made only when an individual is eligible for waiver payments and when the services was included in the plan. The Iowa Department of Human Services Bureau of Purchased Services performs financial audits on providers to ensure the services were provided. The Case Manager also ensures that the services were provided.



e. Billing and Claims Record Maintenance Requirement. Records documenting the audit trail of adjudicated claims (including supporting documentation) are maintained by the Medicaid agency, the operating agency specified in Appendix A (if applicable), and providers of waiver services for a minimum period of 3 years as required in 45 CFR §74.53.
APPENDIX I-3: Payment

a. Method of payments — MMIS (select one):




Payments for all waiver services are made through an approved Medicaid Management Information System (MMIS).

x

Payments for some, but not all, waiver services are made through an approved MMIS. Specify: (a) the waiver services for which payment is not made through an approved MMIS; (b) the process for making such 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.


The financial management service bill the MMIS for services and goods and will make payments to consumer employed workers and entities that provide supports and goods for consumers that self-direct. All payments will be tracked through ISIS. In addition the financial management service will supply to the state quarterly reports on what and who was paid so that the state may draw down federal funds. The financial management service will be subject to yearly audits. Providers may receive payment form the Medicaid agency directly.





Payments for waiver services are not made through an approved MMIS. Specify: (a) the process by which payments are made; (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:



b. Direct payment. Payments for waiver services are made utilizing one or more of the following arrangements. (check each that applies):

X

The Medicaid agency makes payments directly to providers of waiver services.



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

X


The Medicaid agency pays providers through the use of a limited fiscal agent that functions only to pay waiver claims. Specify the limited fiscal agent, 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:

For the self direction option of the waivers, payments will be made to a financial management service, who will be designated by the state as an organized healthcare delivery system to make payments to the entities providing support and goods for consumers that self direct. The financial management service must meet provider qualification established by the state and pass a readiness review approved by the state and be enrolled as a Medicaid provider with the state. The state will also oversee the operations of the financial management service by provide periodical audits.


c. 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:

X

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 and (b) the types of providers to which such payments are made. 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.




d. Payments to Public Providers. Specify whether public providers receive payment for their provision of waiver services.



Yes. Public providers receive payment for waiver services. Specify the types of public providers that receive payment for waiver services, the services that the public providers furnish, and whether the amount of the payment to public providers differs from the amount paid to private providers of the same services: Complete item I-3-e.



X

No. Public providers do not receive payment for waiver services. Do not complete Item
I-3-e.


e. Amount of Payment to Public Providers. Specify whether any public provider receives payments (including regular and any supplemental payments) that in the aggregate exceed its reasonable costs of providing waiver services and, if so, how the State recoups the excess and returns the Federal share of the excess to CMS on the quarterly expenditure report. Select one:

X

No public provider receives payments that in the aggregate exceed its reasonable costs of providing waiver services.



When a public 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:



f. 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:

X

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



Providers do not receive and retain 100 percent of the amount claimed to CMS for waiver services. Provide a full description of the billing, claims, or payment processes that result in less than 100% reimbursement of providers. Include: (a) the methodology for reduced or returned payments; (b) a complete listing of types of providers, the amount or percentage of payments that are reduced or returned; and, (c) the disposition and use of the funds retained or returned to the State (i.e., general fund, medical services account, etc.):



g. Additional Payment Arrangements

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




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.



X

The State does not provide that providers may voluntarily reassign their right to direct payments to a governmental agency.

ii. Organized Health Care Delivery System. Select one:

X

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:


The Financial Management Services entities will be designated as an OHCDS as long as they meet provider qualifications as specified in C- 3. Iowa Medicaid Enterprise, (the state Medicaid agency) will execute a provider agreement with the OHCDS providers. The Financial Management Services provided by the OHCDS will be voluntary and an alternative billing and access will be provided to both waiver participants and providers. Consumers will have free choice of providers both within the OHCDS and external to these providers. Providers may use the alternative certification and billing process that will be developed by the Iowa Medicaid Enterprise. Consumers will be given this information during their service plan development. Providers will be given this information by the OHCDS. The Designated OHCDS will review and certify that established provider qualifications have been met for each individual or vender receiving Medicaid reimbursement. Annually each provider will be recertified as a qualified provider. Employer/employee agreements and timesheets will document the services provided if waiver consumer elect to hire and manage their own workers. The purchase of goods and services will be documented through receipts and/or invoices. For each purchase Medicaid funding from the MMIS to the provider of the service will be accurately and appropriately tracked through the use of Iowa’s ISIS system Financial oversight and monitoring of the OHCDS will be administered by the Iowa Medicaid Enterprise through an initial readiness review to determine capacity to performed the waiver services and throughout the year using a reporting system, random case file studies and the regular Medicaid audit process




No. The State does not employ Organized Health Care Delivery System (OHCDS) arrangements under the provisions of 42 CFR §447.10.


iii. Contracts with PIHPs or PAHPs. Select one:



The State contracts with 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 prepaid health plans. Contracts with these health plans are on file at the State Medicaid agency. Describe: (a) the 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 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.

X

The State does not contract with PIHPs or PAHPs for the provision of waiver services.

APPENDIX I-4: Non-Federal Matching Funds

a. 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. Check each that applies:


X

Appropriation of State Tax Revenues to the State Medicaid agency

X

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

The Department of Elder Affairs is appropriated state funds for the state match for case management services under the Elderly waiver. On a quarterly basis the Department of Elder Affairs will transfer an even amount to the Department of Human Services




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

b. Local 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. Check each that applies:




Appropriation of Local Revenues. Specify: (a) the local 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 as CPEs, as specified in Item I-2- c:





Other non-State Level Source(s) of Funds. Specify: (a) the source of funds; (b) the 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 as CPEs, as specified in Item I-2- c:



X

Not Applicable. There are no non-State level sources of funds for the non-federal share.

c. Information Concerning Certain Sources of Funds. Indicate whether any of the sources of funds listed in items (a) or (b) for the non-federal share of computable waiver costs come from the following sources. Check each that applies.




Provider taxes or fees



Provider donations



Federal funds (other than FFP)




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



X

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

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

a. Services Furnished in Residential Settings. Select one:



No services under this waiver are furnished in residential settings other than the personal residence of the individual. (Do not complete the remainder of this part).

X

As specified in Appendix C, the State furnishes waiver services in residential settings other than the personal home of the individual. (Complete the next item)

b. 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:

As specified in Iowa Administrative code, Iowa does not reimburse for room and board costs. All providers of waiver services are subject to a billing audit completed by the Department of Human Services Bureau of Purchased services.





APPENDIX I-6: Payment for Rent and Food Expenses

of an Unrelated Live-In Caregiver

Reimbursement for the Rent and Food Expenses of an Unrelated Live-In Personal Caregiver. Select one:



Yes. Per 42 CFR §441.310(a)(2)(ii), the State will claim FFP for the additional costs of rent and food that can be reasonably attributed to an unrelated live-in personal caregiver who resides in the same household as the waiver participant. The State describes its coverage of live-in caregiver in Appendix C-3 and the costs attributable to rent and food for the live-in caregiver are reflected separately in the computation of factor D (cost of waiver services) in Appendix J. FFP for rent and food for a live-in caregiver will not be claimed when the participant lives in the caregiver’s home or in a residence that is owned or leased by the provider of Medicaid services. The following is an explanation of: (a) the method used to apportion the additional costs of rent and food attributable to the unrelated live-in personal caregiver that are incurred by the individual served on the waiver and (b) the method used to reimburse these costs:



X

No. The State does not reimburse for the rent and food expenses of an unrelated live-in personal caregiver who resides in the same household as the participant.

APPENDIX I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing

a. Co-Payment Requirements. Specify whether the State imposes a co-payment or similar charge upon waiver participants for waiver services as provided in 42 CFR §447.50. These charges are calculated per service and have the effect of reducing the total computable claim for federal financial participation. Select one:



No. The State does not impose a co-payment or similar charge upon participants for waiver services. (Do not complete the remaining items; proceed to Item I-7-b).

X

Yes. The State imposes a co-payment or similar charge upon participants for one or more waiver services. (Complete the remaining items)

i. Co-Pay Arrangement Specify the types of co-pay arrangements that are imposed on waiver participants (check each that applies):

Charges Associated with the Provision of Waiver Services (if any are checked, complete Items I-7-a-ii through I-7-a-iv):

Nominal deductible




Coinsurance



Co-Payment

X

Other charge (specify):

The consumer’s total monthly income is determined, then 300% of the SSI benefit for one person is subtracted. Then any medical assistance trust funds are counted, the result is the consumers participation amount. These co payments are accounted for on the CMS-64 as expenses minus the co payments


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