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


Participants Subject to Co-pay Charges for Waiver Services



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Participants Subject to Co-pay Charges for Waiver Services. Specify the groups of waiver participants who are subject to charges for the waiver services specified in Item I-7-b-iii and the groups for whom such charges are excluded. The groups of participants who are excluded must comply with 42 CFR §447.53.


NA


iii. Amount of Co-Pay Charges for Waiver Services. In the following table, list the waiver services for which a charge is made, the amount of the charge, and the basis for determining the charge. The amount of the charge must comply with the maximum amounts set forth in 42 CFR §447.54.

Waiver Service

Amount of Charge

Basis of the Charge

All services authorized would be included with consumer participation amount



























































iv. Cumulative Maximum Charges. Indicate whether there is a cumulative maximum amount for all co-payment charges to a waiver participant (select one):

X

There is no cumulative maximum for all deductible, coinsurance or co-payment charges to a waiver participant.



There is a cumulative maximum for all deductible, coinsurance or co-payment charges to a waiver participant. Specify the cumulative maximum and the time period to which the maximum applies:




v. Assurance. In accordance with 42 CFR §447.53(e), the State assures that no provider may deny waiver services to an individual who is eligible for the services on account of the individual's inability to pay a cost-sharing charge for a waiver service.

b. Other State Requirement for Cost Sharing. Specify whether the State imposes a premium, enrollment fee or similar cost sharing on waiver participants as provided in 42 CFR §447.50. Select one:

X

No. The State does not impose a premium, enrollment fee, or similar cost-sharing arrangement on waiver participants.




Yes. The State imposes a premium, enrollment fee or similar cost-sharing arrangement. Describe in detail the cost sharing arrangement, including: (a) the type of cost sharing (e.g., premium, enrollment fee); (b) the amount of charge and how the amount of the charge is related to total gross family income as set forth in 42 CFR §447.52; (c) the groups of participants subject to cost-sharing and the groups who are excluded (groups of participants who are excluded must comply with 42 CFR §447.53); and, (d) the mechanisms for the collection of cost-sharing and reporting the amount collected on the CMS 64:



Appendix J: Cost Neutrality Demonstration

Appendix J-1: Composite Overview and Demonstration

of Cost-Neutrality Formula

Composite Overview. Complete the following table for each year of the waiver. If there is more than one level of care specified in the waiver, complete a separate additional table for each and include a table that reflects the weighted average of the combined levels of care offered in the program.

Level of Care (1) (specify):

SNF

Col. 1


Col. 2

Col. 3

Col. 4

Col. 5

Col. 6

Col. 7

Col. 8

Year

Factor D

Factor D

Total:

D+D

Factor G

Factor G

Total:

G+G

Difference

(Column 7 less Column 4)

1






















2




















3

4,426

11,662

16,088

19,125

5815

24,940

8,852

4

4,536

12,245

16,781

20,081

6,106

26,187

9,406

5

4,644

12,858

17,502

21,086

6,411

27,497

9,995





Level of Care (2) (specify):




Col. 1

Col. 2

Col. 3

Col. 4

Col. 5

Col. 6

Col. 7

Col. 8

Year

Factor D

Factor D

Total:

D+D

Factor G

Factor G

Total:

G+G

Difference

(Column 7 less Column 4)

1




















2






















3






















4






















5























Weighted Average

Col. 1

Col. 2

Col. 3

Col. 4

Col. 5

Col. 6

Col. 7

Col. 8

Year

Factor D

Factor D

Total:

D+D

Factor G

Factor G

Total:

G+G

Difference

(Column 7 less Column 4)

1





















2























3






















4






















5























Appendix J-2 - Derivation of Estimates

a. Number Of Unduplicated Participants Served. As specified in Appendix B-2, the following table shows the maximum number of unduplicated participants who will be served each year that the waiver is in operation:


Table: J-2-a

Waiver Year

Unduplicated Number

of Participants



Year 1




Year 2




Year 3

9726

Year 4 (renewal only)

11,379

Year 5 (renewal only)

13,314

b. Phase-In/Phase-Out Schedule. Indicate whether the waiver is being phased-in or phased-out (select one):

X

The waiver is not subject to a phase-in or a phase-out schedule.



The waiver is being phased-in or phased-out. Attachment #1 to Appendix J-2 specifies the phase-in or phase-out schedule.

c. Average Length of Stay. Describe the basis of the estimate of the average length of stay on the waiver by participants in item J-2-e.

Estimate based on the 372 reports




d. Derivation of Estimates for Each Factor. Provide a narrative description for the derivation of the estimates of the following factors.

i. Factor D Derivation. The estimates of Factor D for each waiver year are located in Item J-2-e. The basis for these estimates is as follows:

Unduplicated # of users for each service was based on the number of recipients from the previous 372 when the waiver was renewed July 2003, an increase by 17% was added to unduplicated users for each year. The average annual number of units per recipients for each services was based on the expenditures from the 372 divided by the rate for reach service to obtain the total number of unites used, this was then divided by the number of recipients to obtain the average number of units used per recipient. The average unit costs includes and increase of 3%




ii. Factor D Derivation. The estimates of Factor D’ for each waiver year are included in
Item J-1. The basis of these estimates is as follows:

D” calculations assume a 5% increase. This comes from the MMIS system for other paid Medicaid services




iii. Factor G Derivation. The estimates of Factor G for each waiver year are included in Item J-1. The basis of these estimates is as follows:


These estimates from actual paid claims and the 372 report

iv. Factor G Derivation. The estimates of Factor G’ for each waiver year are included in Item J-1. The basis of these estimates is as follows:

Actual paid claims and number of recipients, with a 5% increase each year




e. Estimate of Factor D. Complete the following table for each waiver year

Waiver Year: Year 3 SNF

Waiver Service

Col. 1

Col. 2

Col. 3

Col. 4

Col. 5

Unit

# Users

Avg. Units

Per User

Avg. Cost/

Unit

Total Cost

Adult Day Care




















Extended Day

7

27 days

49.33/day

9,323




Full Day

564

69 days

42.58/day

1,657,043




Half Day

163

37 half-days

22.53/day

135,878

Assistive Devices




1898

3 units


51.31/unit

292,159

CDAC



















Agency, non- assisted living - Daily

38

112 days

36.00/day

153,216




Agency, non-assisted living - Hourly

346

168 hrs

17.11/hr

994,570




Individual – Daily

294

206 days

33.17


2,008,908




Individual – Hourly

1444

563 hrs

9.79/hr

7,958,996




Assisted Living

219

6 months

1,012.11/mo

1,329,913

Chore Service




1045

61 half-hr

7.39/half-hr

471,076

Homemaker




5270

87 hrs


19.11/hr

8,761,744

Home Health Aide




94

36 hrs

37.35/hr

126,392

Nursing Care




168

10 visits

74.94/visit

125,899

Respite: Home Health Aide



















Specialized

16

57 hrs

40.40/hr

36,845




Basic

385

96 hrs

20.48/hr

756,941




Group

0

0 hrs

12.99/hr

0

Respite: Home Care Agency



















Specialized

0

0 hrs

33.42/hr

0




Basic

123

170 hrs

15.16/hr


316,996




Group

1

155 hrs

7.20/hr

1,116

Respite: Facility



















Hospital

12

232

7.21/hr

20,073




Nursing Facility

25

461

5.36/hr

61,774



Camps

0

0 hrs

12.99/hr

0




Adult Day Care

0

0 hrs

12.99/hr

0

Mental Health Outreach




207

40 hrs

21.66/hr

179,345

Home & Vehicle Mod.




323

1 unit

524.31/unit

169,352

Home Delivered Meals



6491


175 meals

5.07/meal

5,759,140

PERS




6687

8 mo

28.61

1,530,521

PERS Install




1414

1 install

33.93/install

47,977

Senior Companion




210

290 hrs

4.26/hr

259,434

Transportation











0




RTA

28

259 miles

0.31/mile

2,248




AAA

1192

61 trips

6.54/trip

475,536

Nutritional Counseling




230

9 qtr hrs

8.06/qtr hr

16,684

Case Management




9726

8 moo

114/mo

8,870,112


Financial Management Service




194

8 mo

65 per month

100,880

Independent Support Broker




194

8 mo

25 per month

38,800

Self Directed Personal Care service




65

8 mo

264

137,280

Individual Directed Goods and Services




65

8 mo

264

137,280

Self directed community supports and employment





64

8 mo

264

135,168

GRAND TOTAL:

43,078,619

TOTAL ESTIMATED UNDUPLICATED PARTICIPANTS (from Table J-2-a)

9,726

FACTOR D (Divide total by number of participants)

4,426

AVERAGE LENGTH OF STAY ON THE WAIVER

264 days




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