The Revised The Revised §§1915(c) Waiver 1915(c) Waiver

ApplicationApplicationCMS TeleconferencesCMS TeleconferencesChanges to the HCBS 1915 (c) WaiverChanges to the HCBS 1915 (c) Waiver

August 8August 8thth & 15 & 15thth, 2005, 2005

Presenter:Presenter:Nancy Thaler, CMSNancy Thaler, CMS

Topics to be coveredTopics to be covered

Application’s role in CMS over sightApplication’s role in CMS over sight New Application New Application

Major MilestonesMajor Milestones Policy changes and clarificationsPolicy changes and clarifications

Time Table and Key ActivitiesTime Table and Key Activities Draft Application Version 3.2Draft Application Version 3.2 What if you don’t use the new What if you don’t use the new

application?application?

This is Part of This is Part of Changing CMS Changing CMS

Over-sight Over-sight

Past ApproachPast Approach Application had little Application had little

information about quality information about quality and CMS had no and CMS had no requirements for states to requirements for states to report on quality report on quality

CMS staff did an on site CMS staff did an on site inspection…once in five inspection…once in five yearsyears

Small sample (<25) of Small sample (<25) of people in systems with people in systems with 25,000 – 50,000 people25,000 – 50,000 people

New ApproachNew Approach State build quality and self-direction into the State build quality and self-direction into the

design of their waiver application design of their waiver application

State monitors individuals and fixes State monitors individuals and fixes problemsproblems

State collects and analyzes data forState collects and analyzes data fortrends and patterns across populationstrends and patterns across populations

State makes changes to policy, practices State makes changes to policy, practices and resources based on their analysisand resources based on their analysis

States report the QM activity and results States report the QM activity and results to CMS and the publicto CMS and the public

CMS maintains and on “going dialogue” CMS maintains and on “going dialogue” with states and looks for evidence of state with states and looks for evidence of state over-sightover-sight

Waiver Applicatio

n

Waiver Applicatio

n

The HCBS Waiver Quality Life CycleThe HCBS Waiver Quality Life Cycle

Year 1Year 1

Year 5Year 5

Year 4Year 4

Year 3Year 3

Year 2Year 2

Phone Calls/Emails Onsite Visits

Evidentiary ReportsCMS 372’s

CMS Assess-

mentReport

CMS Assess-

mentReport

Renewal Application with

QM Strategy

State Submits to CMS State Ongoing Communication

Initial W

aivers Receive D

raft Assessm

ent R

epo

rts

Renewed Waivers Receive Draft Assessment Reports

CMS

Initial Application with

QM Strategy

Major MilestonesMajor Milestones

Major milestonesMajor milestones December 2003: Finalize quality framework – December 2003: Finalize quality framework –

agreement to revise applicationagreement to revise application August 2004:First draft issued for comment:August 2004:First draft issued for comment: October 2004 meeting with state associationsOctober 2004 meeting with state associations March 2005: Second Draft and Instructions, Technical March 2005: Second Draft and Instructions, Technical

Guide and Review Criteria issued for commentGuide and Review Criteria issued for comment April 2005: Meeting with State Associations + Cash & April 2005: Meeting with State Associations + Cash &

Counseling StatesCounseling States May 2005: Written comments from states and ROsMay 2005: Written comments from states and ROs May 2005: Draft application available for use on a May 2005: Draft application available for use on a

voluntary basis (Version 3.1)voluntary basis (Version 3.1)

Major milestones (cont’d)Major milestones (cont’d)

March 2005: Second Draft and Instructions, March 2005: Second Draft and Instructions, Technical Guide and Review Criteria issued for Technical Guide and Review Criteria issued for commentcomment

April 2005: Meeting with State Associations + April 2005: Meeting with State Associations + Cash & Counseling StatesCash & Counseling States

May 2005: Written comments from states and May 2005: Written comments from states and ROsROs

May 2005: Draft application available for use May 2005: Draft application available for use on a voluntary basis (Version 3.1)on a voluntary basis (Version 3.1)

14 States using the application for one or more 14 States using the application for one or more waiverswaivers

Policy Changes & Policy Changes & ClarificationsClarifications

New application …New application …

Establishes that a waiver can be subject to a Establishes that a waiver can be subject to a cost-limit less than the cost of institutional cost-limit less than the cost of institutional servicesservices

Explicitly provides for reserving waiver capacityExplicitly provides for reserving waiver capacity Explicitly provides for linking participant limit to Explicitly provides for linking participant limit to

phase-in schedulephase-in schedule Explicitly provides for managing the waiver Explicitly provides for managing the waiver

under a “point in time” participant limitunder a “point in time” participant limit Incorporates CMS expectations for managing Incorporates CMS expectations for managing

qualityquality

New application … New application … (cont’d)(cont’d)

Clarifies policies concerning the provision of Clarifies policies concerning the provision of services by legally responsible individualsservices by legally responsible individuals

Provides for integration of participant-direction Provides for integration of participant-direction opportunities in any programopportunities in any program

Provides a means to phase-in participant Provides a means to phase-in participant direction geographicallydirection geographically

Reduces confusion about waiver administrative Reduces confusion about waiver administrative arrangementsarrangements

Recognizes the use of budget limits on Recognizes the use of budget limits on package of services that individuals receivepackage of services that individuals receive

Time Table &Time Table &Key ActivitiesKey Activities

Time TableTime Table

May-June 2005: Reviewed Version 3.0 May-June 2005: Reviewed Version 3.0 comments and suggestions from statescomments and suggestions from states

June 2005: Lock down application and revise June 2005: Lock down application and revise instructions as necessaryinstructions as necessary

June – September 2005: Design/program web-June – September 2005: Design/program web-based application (MEDSTAT); State user based application (MEDSTAT); State user group convened to review and comment on group convened to review and comment on Appendices screen shots Appendices screen shots

Time Table Time Table (cont’d)(cont’d)

September 2005: Beta-version of application September 2005: Beta-version of application online for testingonline for testing

September 2005 September 2005 Ongoing refinementOngoing refinement Evaluate application and instructions based on user Evaluate application and instructions based on user

and CMS internal feedbackand CMS internal feedback Web Cast demo of the automated application Web Cast demo of the automated application

for Statesfor States January 2006…Go Live with the applicationJanuary 2006…Go Live with the application Jan – April. conduct evaluationJan – April. conduct evaluation

Web-based ApplicationWeb-based Application Electronic preparation and submissionElectronic preparation and submission ““Logic” is designed in, e.g. – Logic” is designed in, e.g. –

Choices drive what appears next (ex: linkage between Choices drive what appears next (ex: linkage between eligibility groups and post-eligibility)eligibility groups and post-eligibility)

Complete once, auto fill in other modules (ex: C-1 service list Complete once, auto fill in other modules (ex: C-1 service list drives C-3 specifications and auto-populates Factor D table in drives C-3 specifications and auto-populates Factor D table in Appendix JAppendix J

Goal: Online – informal RAIs + state responses, Goal: Online – informal RAIs + state responses, changeschanges

Amendments handled onlineAmendments handled online Populate data base to create more robust, accessible Populate data base to create more robust, accessible

information about waiversinformation about waivers No attachmentsNo attachments

EvaluationEvaluation CMS will actively seek state user feedback CMS will actively seek state user feedback

concerning the new applicationconcerning the new application Especially with respect to:Especially with respect to:

Ease of useEase of use BurdenBurden Clarity of application and instructionsClarity of application and instructions

CMS also will evaluate:CMS also will evaluate: Effects on how quickly applications are processedEffects on how quickly applications are processed Whether new application cuts down on RAIsWhether new application cuts down on RAIs Consistency of CMS decision makingConsistency of CMS decision making

Draft ApplicationDraft ApplicationVersion 3.2Version 3.2

Draft Application Version Draft Application Version 3.23.2

For states that want to use new For states that want to use new application right awayapplication right away

May be used for new waivers or renewalsMay be used for new waivers or renewals MS Word Document (not automated)MS Word Document (not automated) Includes changes from Version 3.1Includes changes from Version 3.1 New Instructions are not availableNew Instructions are not available

Using Version 3.2Using Version 3.2

ROs notify states that Version 3.2 is ROs notify states that Version 3.2 is available for voluntary useavailable for voluntary use

State contacts RO to request CD copy State contacts RO to request CD copy and notify of intent to useand notify of intent to use

RO schedules initial conference call with RO schedules initial conference call with state, CO analyst and Deidra Abbottstate, CO analyst and Deidra Abbott

Deidra Abbott will supervise the process Deidra Abbott will supervise the process and final decision makingand final decision making

Review Protocol for V 3.2Review Protocol for V 3.2

Joint RO/CO reviewJoint RO/CO review Assure consistency between RO and CO Assure consistency between RO and CO

and across waiver applicationsand across waiver applications Prompt resolution of questions or Prompt resolution of questions or

problemsproblems Learn from experience and factor new Learn from experience and factor new

knowledge into final versionknowledge into final version

What if you don’t use the What if you don’t use the new application?new application?

The application represents a consensus about The application represents a consensus about what information is critical for CMS to approvewhat information is critical for CMS to approvea waiver applicationa waiver application

Whether States use the new application or the Whether States use the new application or the 1995 Streamlined application, CMS must apply 1995 Streamlined application, CMS must apply the same review standards to all applications. the same review standards to all applications.