Medicaid Waiver Application Guide

Texas must briefly describe the purpose of the waiver program in one page or less (6,000 or fewer characters); its goals, objectives, organizational structure and service delivery methods, and performance assurances. Additional federal requirements that apply to the operation of the waiver program are also addressed.

Appendix A: Waiver Administration and Operations

Texas must identify the day-to-day operation of the waiver along with other entities that are involved in its operation, including as applicable, contracted entities and local/regional non-state operated entities.

Objective: DADS must be able to answer what entities are involved in the operation of the waiver program.

Appendix B: Participant Access and Eligibility

Texas must describe:

  1. the waiver's target group(s);
  2. the individual cost limit (if any) that applies to individuals entering the waiver;
  3. the number of individuals served in the waiver and how this number will be managed during the effective period of the waiver;
  4. the Medicaid eligibility groups served in the waiver;
  5. post eligibility treatment of income policies, if applicable;
  6. procedures for evaluating the level of care for applicants in the waiver and the re-evaluation of the level of care for individuals enrolled in the waiver;
  7. how individuals' are afforded freedom of choice in selecting between institutional and waiver services;
  8. how the state provides for meaningful access to the waiver by individuals with Limited English Proficiency (LEP)

Objective: DADS must be able to answer who receives services in the waiver program.

Appendix C: Participant Services

Texas must describe the following:

  1. all services offered in the waiver, including a description for each service;
  2. service limitations; including the new exception process for the new service limits;
  3. provider qualifications, and whether the service may be participant-directed;
  4. policies concerning criminal history/background and abuse registry checks;
  5. payments to legally responsible individuals for the provision of personal care and to relatives/legal guardians for the provision of services;
  6. services available in adult foster care (AFC) homes;
  7. services available in assisted living/residential care (AL/RC) facilities.

Objective: DADS must be able to describe what services are offered in the waiver.

Appendix D: Participant-Centered Planning and Service Delivery

Texas must describe how the individual centered service plan (individual service plan or ISP) is developed and how Texas monitors the implementation of the ISP and the health and safety of the individual.

Objective: DADS must be able to answer the following:

  1. How are individuals' needs identified and addressed during the ISP development process?
  2. How does the state monitor the delivery of CBA services by the:
    • implementation of the service plan; and
    • individual health and welfare.

Appendix E: Participant Direction of Services

Texas must describe the opportunities afforded individuals who decide to direct and manage their waiver services using the participant direction option (consumer direction services). Appendix E includes:

  1. approach to participant direction (i.e., Consumer Directed Service option or CDS);
  2. participant direction opportunity or opportunities offered under the waiver;
  3. limitations on the election of participant direction;
  4. roles of representatives in participant direction;
  5. services that may be part of participant direction;
  6. provision for financial management services and information and assistance
  7. support of participant direction;
  8. whether independent advocacy is available to participants who direct their services;
  9. circumstances under which participant direction may be terminated; and
  10. state's goals regarding the number of participants who will direct some or all of their waiver services.

Objective: DADS must be able to answer the following:

  1. What authority do individuals have to direct some or all of their CBA services?
  2. How are individuals supported in directing their CBA services?

Appendix F: Participant Rights

Texas must describe how individuals are given the opportunity to request a fair hearing as well as any alternate processes that are available to resolve disputes or address individual complaints or grievances.

Objective: DADS must be able to answer how an individual's rights to services are protected.

Appendix G: Participant Safeguards

Texas must describe how it will identify and follow-up on critical events or incidents (e.g., abuse, neglect and exploitation) that could harm, or potentially harm, an individual receiving waiver services.

Texas must describe how it will manage incidents at the individual and provider level as well as assure that reports are filed and incidents are investigated in a timely fashion. The State must analyze the information in order to develop strategies to reduce the risk and likelihood of incidents in the future.

Objective: DADS must be able to answer what safeguards are established to protect individuals from harm.

Appendix H: Systems Improvement

Texas must describe the system improvement activities based upon the information it gathers from discovery and remediation strategies described throughout the application.

Appendix I: Financial Accountability

The state must describe how it makes payments for waiver services, ensures the integrity of these payments and complies with applicable requirements for federal financial participation. The information will include the following financial elements:

  1. financial integrity and accountability;
  2. rates, billings and claims;
  3. payments;
  4. non-federal matching funds;
  5. exclusion of Medicaid payment for room and board;
  6. payment for rent and food expenses of an unrelated live-in caregiver; and
  7. individual co-payments for waiver services and other cost sharing.

Objective: DADS must be able to answer how Texas maintains financial accountability in the waiver.

Appendix J: Cost Neutrality Demonstration

Texas must provide information that demonstrates the cost neutrality of the waiver program. In order for a waiver to be approved, Texas must show to the satisfaction of CMS that the waiver is cost neutral during each year the waiver is in effect.

Objective: DADS must be able to answer the following:

  1. Does the waiver meet statutory cost-neutrality requirements?