1. The Revised §1915(c) Waiver Application CMS Teleconferences Changes to the HCBS 1915 (c) Waiver August 8 th & 15 th, 2005 Presenter: Nancy Thaler, CMS

2. Topics to be covered  Application’s role in CMS over sight  New Application  Major Milestones  Policy changes and clarifications  Time Table and Key Activities  Draft Application Version 3.2  What if you don’t use the new application?

3. This is Part of Changing CMS Over-sight

4. Past Approach  Application had little information about quality and CMS had no requirements for states to report on quality  CMS staff did an on site inspection…once in five years  Small sample (<25) of people in systems with 25,000 – 50,000 people

5. New Approach  State build quality and self-direction into the design of their waiver application  State monitors individuals and fixes problems  State collects and analyzes data for trends and patterns across populations  State makes changes to policy, practices and resources based on their analysis  States report the QM activity and results to CMS and the public  CMS maintains and on “going dialogue” with states and looks for evidence of state over-sight Waiver Applicatio n Waiver Applicatio n

6. The HCBS Waiver Quality Life Cycle Phone Calls/Emails Onsite Visits Evidentiary Reports CMS 372’s CMS Assess- ment Report CMS Assess- ment Report Renewal Application with QM Strategy State Submits to CMS State Ongoing Communication Initial Waivers Receive Draft Assessment Reports Renewed Waivers Receive Draft Assessment Reports CMS Initial Application with QM Strategy

7. Major Milestones

8. Major milestones  December 2003: Finalize quality framework – agreement to revise application  August 2004:First draft issued for comment:  October 2004 meeting with state associations  March 2005: Second Draft and Instructions, Technical Guide and Review Criteria issued for comment  April 2005: Meeting with State Associations + Cash & Counseling States  May 2005: Written comments from states and ROs  May 2005: Draft application available for use on a voluntary basis (Version 3.1)

9. Major milestones (cont’d)  March 2005: Second Draft and Instructions, Technical Guide and Review Criteria issued for comment  April 2005: Meeting with State Associations + Cash & Counseling States  May 2005: Written comments from states and ROs  May 2005: Draft application available for use on a voluntary basis (Version 3.1)  14 States using the application for one or more waivers

10. Policy Changes & Clarifications

11. New application …  Establishes that a waiver can be subject to a cost-limit less than the cost of institutional services  Explicitly provides for reserving waiver capacity  Explicitly provides for linking participant limit to phase-in schedule  Explicitly provides for managing the waiver under a “point in time” participant limit  Incorporates CMS expectations for managing quality

12. New application … (cont’d)  Clarifies policies concerning the provision of services by legally responsible individuals  Provides for integration of participant-direction opportunities in any program  Provides a means to phase-in participant direction geographically  Reduces confusion about waiver administrative arrangements  Recognizes the use of budget limits on package of services that individuals receive

13. Time Table & Key Activities

14. Time Table  May-June 2005: Reviewed Version 3.0 comments and suggestions from states  June 2005: Lock down application and revise instructions as necessary  June – September 2005: Design/program web- based application (MEDSTAT); State user group convened to review and comment on Appendices screen shots

15. Time Table (cont’d)  September 2005: Beta-version of application online for testing  September 2005   Ongoing refinement  Evaluate application and instructions based on user and CMS internal feedback  Web Cast demo of the automated application for States  January 2006…Go Live with the application  Jan – April. conduct evaluation

16. Web-based Application  Electronic preparation and submission  “Logic” is designed in, e.g. –  Choices drive what appears next (ex: linkage between eligibility groups and post-eligibility)  Complete once, auto fill in other modules (ex: C-1 service list drives C-3 specifications and auto-populates Factor D table in Appendix J  Goal: Online – informal RAIs + state responses, changes  Amendments handled online  Populate data base to create more robust, accessible information about waivers  No attachments

17. Evaluation  CMS will actively seek state user feedback concerning the new application  Especially with respect to:  Ease of use  Burden  Clarity of application and instructions  CMS also will evaluate:  Effects on how quickly applications are processed  Whether new application cuts down on RAIs  Consistency of CMS decision making

18. Draft Application Version 3.2

19. Draft Application Version 3.2  For states that want to use new application right away  May be used for new waivers or renewals  MS Word Document (not automated)  Includes changes from Version 3.1  New Instructions are not available

20. Using Version 3.2  ROs notify states that Version 3.2 is available for voluntary use  State contacts RO to request CD copy and notify of intent to use  RO schedules initial conference call with state, CO analyst and Deidra Abbott  Deidra Abbott will supervise the process and final decision making

21. Review Protocol for V 3.2  Joint RO/CO review  Assure consistency between RO and CO and across waiver applications  Prompt resolution of questions or problems  Learn from experience and factor new knowledge into final version

22. What if you don’t use the new application?  The application represents a consensus about what information is critical for CMS to approve a waiver application  Whether States use the new application or the 1995 Streamlined application, CMS must apply the same review standards to all applications.