1. Request Information (2 of 3)

6. Level(s) of Care. This waiver is requested in order to provide home and community-based waiver services to individuals who, but for the provision of such services, would require the following level(s) of care, the costs of which would be reimbursed under the approved Medicaid State plan (check each that applies):
   Hospital
   Select applicable level of care

    Hospital as defined in 42 CFR §440.10

   If applicable, specify whether the State additionally limits the waiver to subcategories of the hospital level of care:

   Character Count: out of 6000

    Inpatient psychiatric facility for individuals age 21 and under as provided in42 CFR §440.160

    not selected
   Nursing Facility
   Select applicable level of care

    Nursing Facility As defined in 42 CFR §440.40 and 42 CFR §440.155

   If applicable, specify whether the State additionally limits the waiver to subcategories of the nursing facility level of care:

   Character Count: out of 6000

    Institution for Mental Disease for persons with mental illnesses aged 65 and older as provided in 42 CFR §440.140

    not selected
   Intermediate Care Facility for the Mentally Retarded (ICF/MR) (as defined in 42 CFR §440.150)
   If applicable, specify whether the State additionally limits the waiver to subcategories of the ICF/MR level of care:

   Character Count: out of 6000

1. Request Information (3 of 3)

7. Concurrent Operation with Other Programs. This waiver operates concurrently with another program (or programs) approved under the following authorities
   Select one:
    Not applicable
    Applicable
   Check the applicable authority or authorities:

   Services furnished under the provisions of §1915(a)(1)(a) of the Act and described in Appendix I

   Waiver(s) authorized under §1915(b) of the Act.

   Specify the §1915(b) waiver program and indicate whether a §1915(b) waiver application has been submitted or previously approved:

   Character Count: out of 6000

   Specify the §1915(b) authorities under which this program operates (check each that applies):

   §1915(b)(1) (mandated enrollment to managed care)

   §1915(b)(2) (central broker)

   §1915(b)(3) (employ cost savings to furnish additional services)

   §1915(b)(4) (selective contracting/limit number of providers)

   A program operated under §1932(a) of the Act.

   Specify the nature of the State Plan benefit and indicate whether the State Plan Amendment has been submitted or previously approved:

   Character Count: out of 6000

   A program authorized under §1915(i) of the Act.

   A program authorized under §1915(j) of the Act.

   A program authorized under §1115 of the Act.

   Specify the program:

   Character Count: out of 6000

   Not applicable
    not selected

2. Brief Waiver Description

3. Components of the Waiver Request

The waiver application consists of the following components. Note: Item 3-E must be completed.

1. Waiver Administration and Operation. Appendix A specifies the administrative and operational structure of this waiver.

2. Participant Access and Eligibility. Appendix B specifies the target group(s) of individuals who are served in this waiver, the number of participants that the State expects to serve during each year that the waiver is in effect, applicable Medicaid eligibility and post-eligibility (if applicable) requirements, and procedures for the evaluation and reevaluation of level of care.

3. Participant Services. Appendix C specifies the home and community-based waiver services that are furnished through the waiver, including applicable limitations on such services.

4. Participant-Centered Service Planning and Delivery. Appendix D specifies the procedures and methods that the State uses to develop, implement and monitor the participant-centered service plan (of care).

5. Participant-Direction of Services. When the State provides for participant direction of services, Appendix E specifies the participant direction opportunities that are offered in the waiver and the supports that are available to participants who direct their services. (Select one):
    Yes. This waiver provides participant direction opportunities. Appendix E is required.

    No. This waiver does not provide participant direction opportunities. Appendix E is not required.

    not selected

6. Participant Rights. Appendix F specifies how the State informs participants of their Medicaid Fair Hearing rights and other procedures to address participant grievances and complaints.

7. Participant Safeguards. Appendix G describes the safeguards that the State has established to assure the health and welfare of waiver participants in specified areas.

8. Quality Improvement Strategy. Appendix H contains the Quality Improvement Strategy for this waiver.

9. Financial Accountability. Appendix I describes the methods by which the State makes payments for waiver services, ensures the integrity of these payments, and complies with applicable federal requirements concerning payments and federal financial participation.

10. Cost-Neutrality Demonstration. Appendix J contains the State's demonstration that the waiver is cost-neutral.

4. Waiver(s) Requested

1. Comparability. The State requests a waiver of the requirements contained in §1902(a)(10)(B) of the Act in order to provide the services specified in Appendix C that are not otherwise available under the approved Medicaid State plan to individuals who: (a) require the level(s) of care specified in Item 1.F and (b) meet the target group criteria specified in Appendix B.
2. Income and Resources for the Medically Needy. Indicate whether the State requests a waiver of §1902(a)(10)(C)(i)(III) of the Act in order to use institutional income and resource rules for the medically needy (select one):
    Not Applicable

    No

    Yes

    not selected
3. Statewideness. Indicate whether the State requests a waiver of the statewideness requirements in §1902(a)(1) of the Act (select one):

   No

   Yes

   If yes, specify the waiver of statewideness that is requested (check each that applies):

   Geographic Limitation. A waiver of statewideness is requested in order to furnish services under this waiver only to individuals who reside in the following geographic areas or political subdivisions of the State.

   Specify the areas to which this waiver applies and, as applicable, the phase-in schedule of the waiver by geographic area:

   Character Count: out of 6000

   Limited Implementation of Participant-Direction. A waiver of statewideness is requested in order to make participant-direction of services as specified in Appendix E available only to individuals who reside in the following geographic areas or political subdivisions of the State. Participants who reside in these areas may elect to direct their services as provided by the State or receive comparable services through the service delivery methods that are in effect elsewhere in the State.

   Specify the areas of the State affected by this waiver and, as applicable, the phase-in schedule of the waiver by geographic area:

   Character Count: out of 6000

5. Assurances

1. Health & Welfare: The State assures that necessary safeguards have been taken to protect the health and welfare of persons receiving services under this waiver. These safeguards include:

   1. As specified in Appendix C, adequate standards for all types of providers that provide services under this waiver;

   2. Assurance that the standards of any State licensure or certification requirements specified in Appendix C are met for services or for individuals furnishing services that are provided under the waiver. The State assures that these requirements are met on the date that the services are furnished; and,

   3. Assurance that all facilities subject to §1616(e) of the Act where home and community-based waiver services are provided comply with the applicable State standards for board and care facilities as specified in Appendix C.

2. Financial Accountability. The State assures financial accountability for funds expended for home and community-based services and maintains and makes available to the Department of Health and Human Services (including the Office of the Inspector General), the Comptroller General, or other designees, appropriate financial records documenting the cost of services provided under the waiver. Methods of financial accountability are specified in Appendix I.

3. Evaluation of Need: The State assures that it provides for an initial evaluation (and periodic reevaluations, at least annually) of the need for a level of care specified for this waiver, when there is a reasonable indication that an individual might need such services in the near future (one month or less) but for the receipt of home and community based services under this waiver. The procedures for evaluation and reevaluation of level of care are specified in Appendix B.

4. Choice of Alternatives: The State assures that when an individual is determined to be likely to require the level of care specified for this waiver and is in a target group specified in Appendix B, the individual (or, legal representative, if applicable) is:

   1. Informed of any feasible alternatives under the waiver; and,

   2. Given the choice of either institutional or home and community based waiver services. Appendix B specifies the procedures that the State employs to ensure that individuals are informed of feasible alternatives under the waiver and given the choice of institutional or home and community-based waiver services.

5. Average Per Capita Expenditures: The State assures that, for any year that the waiver is in effect, the average per capita expenditures under the waiver will not exceed 100 percent of the average per capita expenditures that would have been made under the Medicaid State plan for the level(s) of care specified for this waiver had the waiver not been granted. Cost-neutrality is demonstrated in Appendix J.

6. Actual Total Expenditures: The State assures that the actual total expenditures for home and community-based waiver and other Medicaid services and its claim for FFP in expenditures for the services provided to individuals under the waiver will not, in any year of the waiver period, exceed 100 percent of the amount that would be incurred in the absence of the waiver by the State's Medicaid program for these individuals in the institutional setting(s) specified for this waiver.

7. Institutionalization Absent Waiver: The State assures that, absent the waiver, individuals served in the waiver would receive the appropriate type of Medicaid-funded institutional care for the level of care specified for this waiver.

8. Reporting: The State assures that annually it will provide CMS with information concerning the impact of the waiver on the type, amount and cost of services provided under the Medicaid State plan and on the health and welfare of waiver participants. This information will be consistent with a data collection plan designed by CMS.

9. Habilitation Services. The State assures that prevocational, educational, or supported employment services, or a combination of these services, if provided as habilitation services under the waiver are: (1) not otherwise available to the individual through a local educational agency under the Individuals with Disabilities Education Act (IDEA) or the Rehabilitation Act of 1973; and, (2) furnished as part of expanded habilitation services.

10. Services for Individuals with Chronic Mental Illness. The State assures that federal financial participation (FFP) will not be claimed in expenditures for waiver services including, but not limited to, day treatment or partial hospitalization, psychosocial rehabilitation services, and clinic services provided as home and community-based services to individuals with chronic mental illnesses if these individuals, in the absence of a waiver, would be placed in an IMD and are: (1) age 22 to 64; (2) age 65 and older and the State has not included the optional Medicaid benefit cited in 42 CFR §440.140; or (3) age 21 and under and the State has not included the optional Medicaid benefit cited in 42 CFR § 440.160.

7. Contact Person(s)

1. The Medicaid agency representative with whom CMS should communicate regarding the waiver is:

   Last Name:
   First Name:
   Title:
   Agency:
   Address:
   Address 2:
   City:
   State:	Utah
   Zip:
   Phone:	Ext: TTY
   Fax:
   E-mail:

2. If applicable, the State operating agency representative with whom CMS should communicate regarding the waiver is:

   Last Name:
   First Name:
   Title:
   Agency:
   Address:
   Address 2:
   City:
   State:	Utah
   Zip:
   Phone:	Ext: TTY
   Fax:
   E-mail:

Attachment #1: Transition Plan

Additional Needed Information (Optional)

Appendix A: Waiver Administration and Operation

7. Distribution of Waiver Operational and Administrative Functions. In the following table, specify the entity or entities that have responsibility for conducting each of the waiver operational and administrative functions listed (check each that applies):
   In accordance with 42 CFR §431.10, when the Medicaid agency does not directly conduct a function, it supervises the performance of the function and establishes and/or approves policies that affect the function. All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. Note: More than one box may be checked per item. Ensure that Medicaid is checked when the Single State Medicaid Agency (1) conducts the function directly; (2) supervises the delegated function; and/or (3) establishes and/or approves policies related to the function.

   Function	Medicaid Agency	Other State Operating Agency
   Participant waiver enrollment
   Waiver enrollment managed against approved limits
   Waiver expenditures managed against approved levels
   Level of care evaluation
   Review of Participant service plans
   Prior authorization of waiver services
   Utilization management
   Qualified provider enrollment
   Execution of Medicaid provider agreements
   Establishment of a statewide rate methodology
   Rules, policies, procedures and information development governing the waiver program
   Quality assurance and quality improvement activities

Appendix A: Waiver Administration and Operation

Quality Improvement: Administrative Authority of the Single State Medicaid Agency

1. Methods for Discovery: Administrative Authority
   The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.

   1. Performance Measures

      For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

      For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

      Performance Measure: The SMA and DSPD collaborate in the development of waiver applications, waiver amendments, rules and other official documents relative to the administration and operation of the waiver. Data Source (Select one): Other If 'Other' is selected, specify: Quarterly meeting minutes, correspondences (email, letters etc), and topic specific meeting minutes. Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: DSPD submits proposed rules and other documents relating to the implementation of the waiver (including training curriculums and outreach materials) to the SMA for review and approval prior to implementation. Data Source (Select one): Other If 'Other' is selected, specify: Document approval forms and DSPD Documents Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: The SMA approves maximum allowable rates (MARs) for covered waiver services. Data Source (Select one): Other If 'Other' is selected, specify: Rate setting meetings minutes, approval documentation, and correspondence Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Disenrollment. Prior to involuntary disenrollment from the waiver DSPD explores all reasonable alternatives and the Disenrollment Protocol has been completed. Final authority for involuntary disenrollment resides with the SMA. Data Source (Select one): Other If 'Other' is selected, specify: Disenrollment documents and correspondence between the SMA and DSPD. Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Timely notice of appeal rights are provided to waiver applicant/participants who make one of the following claims: a) denied access to Medicaid waiver program, b) denied access to needed services while enrolled in the waiver or c) denied choice of provider if more than one qualified provider was available to render the service. Data Source (Select one): Other If 'Other' is selected, specify: DSPD application denial records and participant records Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: At a minimum every two years Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify: At a minimum every two years

      Performance Measure: DSPD will prepare and submit an annual incident report which includes an analysis of incident data and remediation or quality improvement strategies that address the analysis. Data Source (Select one): Other If 'Other' is selected, specify: Participant records and Form 1-8. Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: DSPD will provide the SMA a copy all quality assurance activities reports which will include an analysis of findings, remediation and quality improvement activities. Data Source (Select one): Other If 'Other' is selected, specify: DSPD annual reviews Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: At a minimum every two years Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify: At a minimum every two years

      Performance Measure: DSPD notifies the SMA of critical incidents and events and submits findings of investigations as per SMA protocol. Data Source (Select one): Other If 'Other' is selected, specify: Critical Incident/Event Findings Operating Agency Report to SMA. Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

   2. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
      Character Count: out of 6000
      The SMA demonstrates ultimate administrative authority and responsibility for the operation of the ABI waiver program through numerous activities including the issuance of policies, rules, and regulations relating to the waiver, the approval of all protocols, documents and trainings that affect any aspect of the ABI waiver operations. Approvals are accomplished through a formal document approval process. The SMA also conducts quarterly meetings with DSPD (the operating agency), monitors compliance with the Interagency Agreement, receives and reviews quarterly ABI Waiver Reports from DSPD, and provides technical assistance to the operating agency and other entities within the state that affect the operation of the waiver program. The SMA conducts an annual review of the ABI program for each of the five Waiver years. At a minimum, one comprehensive review will be conducted during this five year cycle. The comprehensive review will include participant and provider interviews. The other annual reviews will be focused reviews. The criteria for the focused reviews will be determined from DSPD and SMA review findings as well as other issues that develop during the review year. The sample size for each review will be sufficient to provide a confidence level equal to 95% and a confidence interval equal to 5. The SMA is the entity responsible for official communication with CMS for all issues related to the ABI Waiver.
2. Methods for Remediation/Fixing Individual Problems
   1. Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.
      Character Count: out of 6000
      Individual issues identified by DSPD and the SMA that affect the health and welfare of individual participants are addressed immediately. Issues that are less immediate are corrected within designated time frames and are documented through the SMA final review report. When the SMA determines that an issue is resolved, notification is provided and documentation is maintained by the SMA.
   2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)

      Responsible Party (check each that applies):	Frequency of data aggregation and analysis (check each that applies):
      State Medicaid Agency	Weekly
      Operating Agency	Monthly
      Sub-State Entity	Quarterly
      Other Specify:	Annually
      	Continuously and Ongoing
      	Other Specify:

3. Timelines
   When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Financial Accountability that are currently non-operational.

    No

    Yes

    not selected
   Please provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

B-1: Specification of the Waiver Target Group(s)

1. Target Group(s). Under the waiver of Section 1902(a)(10)(B) of the Act, the State limits waiver services to a group or subgroups of individuals. Please see the instruction manual for specifics regarding age limits. In accordance with 42 CFR §441.301(b)(6), select one waiver target group, check each of the subgroups in the selected target group that may receive services under the waiver, and specify the minimum and maximum (if any) age of individuals served in each subgroup:

   Target Group	Included	Target SubGroup	Minimum Age	Maximum Age
   				Maximum Age Limit	No Maximum Age Limit
   Aged or Disabled, or Both - General
   		Aged
   		Disabled (Physical)
   		Disabled (Other)
   Aged or Disabled, or Both - Specific Recognized Subgroups
   		Brain Injury
   		HIV/AIDS
   		Medically Fragile
   		Technology Dependent
   Mental Retardation or Developmental Disability, or Both
   		Autism
   		Developmental Disability
   		Mental Retardation
   Mental Illness
   		Mental Illness
   		Serious Emotional Disturbance
   not selected

2. Additional Criteria. The State further specifies its target group(s) as follows:

   Character Count: out of 12000
   Waiver services are limited to individuals with the following disease(s) or condition(s) 1. Acquired brain injury is defined as being injury related and neurological in nature, and may include cerebral vascular accident and brain injuries that have occurred after birth. Acquired brain injury does not include individuals whose functional limitations are due solely to mental illness, substance abuse, personality disorder, hearing impairment, visual impairment, learning disabilities, behavior disorders, aging process, or individuals with deteriorating diseases such as multiple sclerosis, muscular dystrophy, Huntington’s chorea, ataxia, or cancer. 2. Individuals must meet a qualifying ICD 9 CM diagnoses as outlined in Administrative Rule: R539-1-8 (1)(a). 3. Individual must score between 40 and 120 on the Comprehensive Brain Injury Assessment (CBIA) Form as outlined in Administrative Rule: R539-1-8 (1)(c). 4. This waiver is not available to individuals who have suffered congenital brain injury, or brain injuries induced by birth trauma. 5. This waiver is limited to persons with disabilities who have established eligibility for State matching funds through the Utah Department of Human Services in accordance with UCA 62A-5. 6. If a person is eligible for more than one of the waivers operated by DSPD, the division will educate the individual about their choices and will advise the individual about which of the waivers will likely best meet their needs.

3. Transition of Individuals Affected by Maximum Age Limitation. When there is a maximum age limit that applies to individuals who may be served in the waiver, describe the transition planning procedures that are undertaken on behalf of participants affected by the age limit (select one):

   Not applicable. There is no maximum age limit

   The following transition planning procedures are employed for participants who will reach the waiver's maximum age limit.

   Specify:

   Character Count: out of 12000

Appendix B: Participant Access and Eligibility

B-2: Individual Cost Limit (1 of 2)

1. Individual Cost Limit. The following individual cost limit applies when determining whether to deny home and community-based services or entrance to the waiver to an otherwise eligible individual (select one) Please note that a State may have only ONE individual cost limit for the purposes of determining eligibility for the waiver:
    No Cost Limit. The State does not apply an individual cost limit. Do not complete Item B-2-b or item B-2-c.
    Cost Limit in Excess of Institutional Costs. The State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed the cost of a level of care specified for the waiver up to an amount specified by the State. Complete Items B-2-b and B-2-c.

   The limit specified by the State is (select one)

    A level higher than 100% of the institutional average.

   Specify the percentage:

    Other

   Specify:

   Character Count: out of 6000

    not selected
    Institutional Cost Limit. Pursuant to 42 CFR 441.301(a)(3), the State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed 100% of the cost of the level of care specified for the waiver. Complete Items B-2-b and B-2-c.
    Cost Limit Lower Than Institutional Costs. The State refuses entrance to the waiver to any otherwise qualified individual when the State reasonably expects that the cost of home and community-based services furnished to that individual would exceed the following amount specified by the State that is less than the cost of a level of care specified for the waiver.

   Specify the basis of the limit, including evidence that the limit is sufficient to assure the health and welfare of waiver participants. Complete Items B-2-b and B-2-c.

   Character Count: out of 6000

   The cost limit specified by the State is (select one):

    The following dollar amount:

   Specify dollar amount:

   The dollar amount (select one)

    Is adjusted each year that the waiver is in effect by applying the following formula:

   Specify the formula:

   Character Count: out of 6000

    May be adjusted during the period the waiver is in effect. The State will submit a waiver amendment to CMS to adjust the dollar amount.

    not selected

    The following percentage that is less than 100% of the institutional average:

   Specify percent:

    Other:

   Specify:

   Character Count: out of 6000

    not selected
    not selected

Appendix B: Participant Access and Eligibility

B-2: Individual Cost Limit (2 of 2)

2. Method of Implementation of the Individual Cost Limit. When an individual cost limit is specified in Item B-2-a, specify the procedures that are followed to determine in advance of waiver entrance that the individual's health and welfare can be assured within the cost limit:
   Character Count: out of 12000
3. Participant Safeguards. When the State specifies an individual cost limit in Item B-2-a and there is a change in the participant's condition or circumstances post-entrance to the waiver that requires the provision of services in an amount that exceeds the cost limit in order to assure the participant's health and welfare, the State has established the following safeguards to avoid an adverse impact on the participant (check each that applies):
   The participant is referred to another waiver that can accommodate the individual's needs.
   Additional services in excess of the individual cost limit may be authorized.

   Specify the procedures for authorizing additional services, including the amount that may be authorized:

   Character Count: out of 12000
   Other safeguard(s)

   Specify:

   Character Count: out of 12000

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (1 of 4)

1. Unduplicated Number of Participants. The following table specifies the maximum number of unduplicated participants who are served in each year that the waiver is in effect. The State will submit a waiver amendment to CMS to modify the number of participants specified for any year(s), including when a modification is necessary due to legislative appropriation or another reason. The number of unduplicated participants specified in this table is basis for the cost-neutrality calculations in Appendix J:

   Table: B-3-a

   Waiver Year	Unduplicated Number of Participants
   Year 1
   Year 2
   Year 3
   Year 4 (renewal only)
   Year 5 (renewal only)

2. Limitation on the Number of Participants Served at Any Point in Time. Consistent with the unduplicated number of participants specified in Item B-3-a, the State may limit to a lesser number the number of participants who will be served at any point in time during a waiver year. Indicate whether the State limits the number of participants in this way: (select one):

   The State does not limit the number of participants that it serves at any point in time during a waiver year.

   The State limits the number of participants that it serves at any point in time during a waiver year.

   The limit that applies to each year of the waiver period is specified in the following table:

   Table: B-3-b

   Waiver Year	Maximum Number of Participants Served At Any Point During the Year
   Year 1
   Year 2
   Year 3
   Year 4 (renewal only)
   Year 5 (renewal only)

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (2 of 4)

3. Reserved Waiver Capacity. The State may reserve a portion of the participant capacity of the waiver for specified purposes (e.g., provide for the community transition of institutionalized persons or furnish waiver services to individuals experiencing a crisis) subject to CMS review and approval. The State (select one):

   Not applicable. The state does not reserve capacity.

   The State reserves capacity for the following purpose(s).

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (3 of 4)

4. Scheduled Phase-In or Phase-Out. Within a waiver year, the State may make the number of participants who are served subject to a phase-in or phase-out schedule (select one):

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

   The waiver is subject to a phase-in or phase-out schedule that is included in Attachment #1 to Appendix B-3. This schedule constitutes an intra-year limitation on the number of participants who are served in the waiver.

5. Allocation of Waiver Capacity.

   Select one:

   Waiver capacity is allocated/managed on a statewide basis.

   Waiver capacity is allocated to local/regional non-state entities.

   Specify: (a) the entities to which waiver capacity is allocated; (b) the methodology that is used to allocate capacity and how often the methodology is reevaluated; and, (c) policies for the reallocation of unused capacity among local/regional non-state entities:

   Character Count: out of 12000
6. Selection of Entrants to the Waiver. Specify the policies that apply to the selection of individuals for entrance to the waiver:
   Character Count: out of 12000
   Medicaid recipients who meet the programmatic eligibility requirements as defined in Appendix B-1 are given a choice (in writing) to either receive services to meet the identified needs in a Nursing Facility (NF), or through the Acquired Brain Injury Waiver. If the individual chooses to receive services through the Waiver, available capacity is determined. If available capacity exists, the individual is enrolled in the Waiver. If available capacity does not exist, the applicant will be advised in writing that he or she may access services through a NF or may wait for available capacity in the Acquired Brain Injury Waiver. If the individual chooses to wait for available capacity, the operating agency provides information about community resources to assist the individual in the interim. If the individual is not a Medicaid recipient at the time of application, information will be given on applying for Medicaid. In all cases, the applicant’s choice will be documented in writing, signed by the applicant, and maintained as part of the individual record. As directed by State law, the DSPD has established a Critical Needs Assessment process by which individuals are ranked on a waiting list to prioritize access to Waiver services. A significant component of the Critical Needs Assessment tool addresses the immediacy of the need for services and the individual’s risk in not gaining access to Waiver services. The applicant is placed on a waiting list according to their critical need ranking. The waiting list includes applicants who are seeking to receive Waiver services through DSPD and is not waiver specific.

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served - Attachment #1 (4 of 4)

Appendix B: Participant Access and Eligibility

B-4: Eligibility Groups Served in the Waiver

1. 1. State Classification. The State is a (select one):
       §1634 State
       SSI Criteria State
       209(b) State
       not selected
   2. Miller Trust State.
      Indicate whether the State is a Miller Trust State (select one):
       No
       Yes
       Unknown
2. Medicaid Eligibility Groups Served in the Waiver. Individuals who receive services under this waiver are eligible under the following eligibility groups contained in the State plan. The State applies all applicable federal financial participation limits under the plan. Check all that apply:
   Eligibility Groups Served in the Waiver (excluding the special home and community-based waiver group under 42 CFR §435.217)
   Low income families with children as provided in §1931 of the Act
   SSI recipients
   Aged, blind or disabled in 209(b) states who are eligible under 42 CFR §435.121
   Optional State supplement recipients
   Optional categorically needy aged and/or disabled individuals who have income at:

   Select one:

    100% of the Federal poverty level (FPL)

    % of FPL, which is lower than 100% of FPL.

   Specify percentage:

    not selected
   Working individuals with disabilities who buy into Medicaid (BBA working disabled group as provided in §1902(a)(10)(A)(ii)(XIII)) of the Act)
   Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1902(a)(10)(A)(ii)(XV) of the Act)
   Working individuals with disabilities who buy into Medicaid (TWWIIA Medical Improvement Coverage Group as provided in §1902(a)(10)(A)(ii)(XVI) of the Act)
   Disabled individuals age 18 or younger who would require an institutional level of care (TEFRA 134 eligibility group as provided in §1902(e)(3) of the Act)
   Medically needy
   Medically needy in 209(b) States (42 CFR §435.330)
   Medically needy in 1634 States and SSI Criteria States (42 CFR §435.320, §435.322 and §435.324)
   Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver)

   Specify:

   Character Count: out of 6000

   42 CFR 435.301, 435.308, 435.310, 435.113 1902(a)(10)(A)(i)(III) and 1905(n) 1902(a)(10)(A)(i)(IV) and 1902(1)(1)(A) and 1902(1)(1)(A) and (B) 1902(a)(10)(A)(i)(VII) and 1902(1)(1)(D) 1902(a)(10)(A)(i)(V) and 1905(m) 1902(e)(5), 1902(e)(6) 1902(a)(10)(A)(ii)(XVII)
   Special home and community-based waiver group under 42 CFR §435.217) Note: When the special home and community-based waiver group under 42 CFR §435.217 is included, Appendix B-5 must be completed
    No. The State does not furnish waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217. Appendix B-5 is not submitted.

    Yes. The State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217.

    not selected

   Select one and complete Appendix B-5.

    All individuals in the special home and community-based waiver group under 42 CFR §435.217

    Only the following groups of individuals in the special home and community-based waiver group under 42 CFR §435.217

    not selected

   Check each that applies:

   A special income level equal to:

   Select one:

    300% of the SSI Federal Benefit Rate (FBR)

    A percentage of FBR, which is lower than 300% (42 CFR §435.236)

   Specify percentage:

    A dollar amount which is lower than 300%.

   Specify dollar amount:

    not selected

   Aged, blind and disabled individuals who meet requirements that are more restrictive than the SSI program (42 CFR §435.121)

   Medically needy without spenddown in States which also provide Medicaid to recipients of SSI (42 CFR §435.320, §435.322 and §435.324)

   Medically needy without spend down in 209(b) States (42 CFR §435.330)

   Aged and disabled individuals who have income at:

   Select one:

    100% of FPL

    % of FPL, which is lower than 100%.

   Specify percentage amount:

    not selected

   Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver)

   Specify:

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (1 of 4)

In accordance with 42 CFR §441.303(e), Appendix B-5 must be completed when the State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217, as indicated in Appendix B-4. Post-eligibility applies only to the 42 CFR §435.217 group. A State that uses spousal impoverishment rules under §1924 of the Act to determine the eligibility of individuals with a community spouse may elect to use spousal post-eligibility rules under §1924 of the Act to protect a personal needs allowance for a participant with a community spouse.

1. Use of Spousal Impoverishment Rules. Indicate whether spousal impoverishment rules are used to determine eligibility for the special home and community-based waiver group under 42 CFR §435.217 (select one):

    Spousal impoverishment rules under §1924 of the Act are used to determine the eligibility of individuals with a community spouse for the special home and community-based waiver group.

   In the case of a participant with a community spouse, the State elects to (select one):

    Use spousal post-eligibility rules under §1924 of the Act.

   (Complete Item B-5-b (SSI State) and Item B-5-d)

    Use regular post-eligibility rules under 42 CFR §435.726 (SSI State) or under §435.735 (209b State)

   (Complete Item B-5-b (SSI State) . Do not complete Item B-5-d)

    not selected

    Spousal impoverishment rules under §1924 of the Act are not used to determine eligibility of individuals with a community spouse for the special home and community-based waiver group. The State uses regular post-eligibility rules for individuals with a community spouse.

   (Complete Item B-5-b (SSI State) . Do not complete Item B-5-d)

    not selected

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (2 of 4)

2. Regular Post-Eligibility Treatment of Income: SSI State.

   The State uses the post-eligibility rules at 42 CFR 435.726 for individuals who do not have a spouse or have a spouse who is not a community spouse as specified in §1924 of the Act. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the following allowances and expenses from the waiver participant's income:

   1. Allowance for the needs of the waiver participant (select one):

       The following standard included under the State plan

      Select one:

       SSI standard

       Optional State supplement standard

       Medically needy income standard

       The special income level for institutionalized persons

      (select one):

       300% of the SSI Federal Benefit Rate (FBR)

       A percentage of the FBR, which is less than 300%

      Specify the percentage:

       A dollar amount which is less than 300%.

      Specify dollar amount:

       not selected

       A percentage of the Federal poverty level

      Specify percentage:

       Other standard included under the State Plan

      Specify:

      Character Count: out of 36000

       not selected
       The following dollar amount

      Specify dollar amount: If this amount changes, this item will be revised.
       The following formula is used to determine the needs allowance:

      Specify:

      Character Count: out of 6000

      Up to $125 of any earned income plus an additional general disregard equal to the federal poverty limit for a household of one; plus a shelter cost deduction for actual mortgage & related costs (property taxes, insurance, etc.) or rent, not to exceed $300; & a utility cost deduction of $158 for households which have a heating or cooling expense, or $79 for a household which does not have a heating or cooling expense but has any other utility (water, phone, electricity, etc.).
       Other

      Specify:

      Character Count: out of 6000
       not selected

   2. Allowance for the spouse only (select one):

       Not Applicable
       The state provides an allowance for a spouse who does not meet the definition of a community spouse in §1924 of the Act. Describe the circumstances under which this allowance is provided:

      Specify:

      Character Count: out of 6000

      Specify the amount of the allowance (select one):

       SSI standard

       Optional State supplement standard

       Medically needy income standard

       The following dollar amount:

      Specify dollar amount: If this amount changes, this item will be revised.

       The amount is determined using the following formula:

      Specify:

      Character Count: out of 6000

       not selected
       not selected

   3. Allowance for the family (select one):

       Not Applicable (see instructions)
       AFDC need standard
       Medically needy income standard
       The following dollar amount:

      Specify dollar amount: The amount specified cannot exceed the higher of the need standard for a family of the same size used to determine eligibility under the State's approved AFDC plan or the medically needy income standard established under 42 CFR §435.811 for a family of the same size. If this amount changes, this item will be revised.
       The amount is determined using the following formula:

      Specify:

      Character Count: out of 6000
       Other

      Specify:

      Character Count: out of 6000
       not selected

   4. Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 §CFR 435.726:

      1. Health insurance premiums, deductibles and co-insurance charges
      2. Necessary medical or remedial care expenses recognized under State law but not covered under the State's Medicaid plan, subject to reasonable limits that the State may establish on the amounts of these expenses.

      Select one:

       Not Applicable (see instructions) Note: If the State protects the maximum amount for the waiver participant, not applicable must be selected.
       The State does not establish reasonable limits.
       The State establishes the following reasonable limits

      Specify:

      Character Count: out of 6000

      The State establishes the following reasonable limits: The limits specified in Utah’s Title XIX State Plan for post-eligibility income deductions under 42 CFR 435.725, 435.726, 435.832 and Sec. 1924 of the Social Security Act. The limits are defined on supplement 3 to attachment 2.6A.
       not selected

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (3 of 4)

3. Regular Post-Eligibility Treatment of Income: 209(B) State.

   Answers provided in Appendix B-4 indicate that you do not need to complete this section and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (4 of 4)

4. Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules

   The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care if it determines the individual's eligibility under §1924 of the Act. There is deducted from the participant’s monthly income a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the State Medicaid Plan.. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).

   1. Allowance for the personal needs of the waiver participant

      (select one):
       SSI standard
       Optional State supplement standard
       Medically needy income standard
       The special income level for institutionalized persons
       A percentage of the Federal poverty level

      Specify percentage:
       The following dollar amount:

      Specify dollar amount: If this amount changes, this item will be revised
       The following formula is used to determine the needs allowance:

      Specify formula:

      Character Count: out of 4000

      Up to $125 of any earned income plus an additional general disregard equal to the federal poverty limit for a household of one; plus a shelter cost deduction for actual mortgage & related costs (property taxes, insurance, etc.) or rent, not to exceed $300; & a utility cost deduction of $158 for households which have a heating or cooling expense, or $79 for a household which does not have a heating or cooling expense but has any other utility (water, phone, electricity, etc.).
       Other

      Specify:

      Character Count: out of 36000
       not selected

   2. If the allowance for the personal needs of a waiver participant with a community spouse is different from the amount used for the individual's maintenance allowance under 42 CFR §435.726 or 42 CFR §435.735, explain why this amount is reasonable to meet the individual's maintenance needs in the community.

      Select one:

       Allowance is the same
       Allowance is different.

      Explanation of difference:

      Character Count: out of 6000
       not selected

   3. Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 §CFR 435.726:

      1. Health insurance premiums, deductibles and co-insurance charges
      2. Necessary medical or remedial care expenses recognized under State law but not covered under the State's Medicaid plan, subject to reasonable limits that the State may establish on the amounts of these expenses.

      Select one:

       Not Applicable (see instructions) Note: If the State protects the maximum amount for the waiver participant, not applicable must be selected.
       The State does not establish reasonable limits.
       The State uses the same reasonable limits as are used for regular (non-spousal) post-eligibility.
       not selected

Appendix B: Participant Access and Eligibility

B-6: Evaluation/Reevaluation of Level of Care

1. Reasonable Indication of Need for Services. In order for an individual to be determined to need waiver services, an individual must require: (a) the provision of at least one waiver service, as documented in the service plan, and (b) the provision of waiver services at least monthly or, if the need for services is less than monthly, the participant requires regular monthly monitoring which must be documented in the service plan. Specify the State's policies concerning the reasonable indication of the need for services:

   1. Minimum number of services.

      The minimum number of waiver services (one or more) that an individual must require in order to be determined to need waiver services is:
   2. Frequency of services. The State requires (select one):
       The provision of waiver services at least monthly
       Monthly monitoring of the individual when services are furnished on a less than monthly basis

      If the State also requires a minimum frequency for the provision of waiver services other than monthly (e.g., quarterly), specify the frequency:

      Character Count: out of 4000
       not selected
2. Responsibility for Performing Evaluations and Reevaluations. Level of care evaluations and reevaluations are performed (select one):
    Directly by the Medicaid agency
    By the operating agency specified in Appendix A
    By an entity under contract with the Medicaid agency.

   Specify the entity:

   Character Count: out of 4000
    Other
   Specify:

   Character Count: out of 4000
    not selected
3. Qualifications of Individuals Performing Initial Evaluation: Per 42 CFR §441.303(c)(1), specify the educational/professional qualifications of individuals who perform the initial evaluation of level of care for waiver applicants:

   Character Count: out of 6000
   Acquired Brain Injury Support Coordinator (ABISC) – Certified by DSPD Qualified support coordinators shall possess at least a Bachelors degree in nursing, behavioral science, or a human services related field such as social work, sociology, special education, rehabilitation counseling, or psychology and demonstrate competency relating to the planning and delivery of health services to the Acquired Brain Injury population through successful completion of a training and testing program approved by the State Medicaid Agency.
4. Level of Care Criteria. Fully specify the level of care criteria that are used to evaluate and reevaluate whether an individual needs services through the waiver and that serve as the basis of the State's level of care instrument/tool. Specify the level of care instrument/tool that is employed. State laws, regulations, and policies concerning level of care criteria and the level of care instrument/tool are available to CMS upon request through the Medicaid agency or the operating agency (if applicable), including the instrument/tool utilized.

   Character Count: out of 12000
   Utah Administrative Rule 414-502 defines the State’s level of care for nursing facility care. The rule defines that a client must meet two of the following three criteria: (1) Due to the diagnosed medical conditions, the applicant requires at least substantial physical assistance with activities of daily living above the level of verbal prompting, supervising, or setting up; (2) The attending physician had determined that the applicant’s level of dysfunction in orientation to person, place, or time requires nursing facility; or equivalent care provided through an alternative Medicaid health care delivery program; or (3) The medical condition and intensity of services indicate that the care needs of the applicant cannot be safely met in a less structured setting, or without the services and supports of an alternative Medicaid health care delivery program. The tool used to make this determination is the Comprehensive Brain Injury Assessment (CBIA). The applicant must score between 40 – 120 on this assessment.
5. Level of Care Instrument(s). Per 42 CFR §441.303(c)(2), indicate whether the instrument/tool used to evaluate level of care for the waiver differs from the instrument/tool used to evaluate institutional level of care (select one):
    The same instrument is used in determining the level of care for the waiver and for institutional care under the State Plan.
    A different instrument is used to determine the level of care for the waiver than for institutional care under the State plan.

   Describe how and why this instrument differs from the form used to evaluate institutional level of care and explain how the outcome of the determination is reliable, valid, and fully comparable.

   Character Count: out of 12000

   The primary instrument used to determine level of care in nursing facilities is the Minimum Data Set (MDS) assessment. Because this assessment was designed to determine the needs of individuals residing in facility based settings, the state utilizes a tool that assesses the same elements, but that is geared toward assessing a person’s needs and abilities in a community based setting. The Comprehensive Brain Injury Assessment (CBIA) serves as the standard comprehensive assessment instrument for this waiver and includes all the data fields necessary to measure the individual’s level of care as defined in the state’s Medicaid nursing facility admission criteria. It contains a thorough assessment of the individual’s diagnostic and other health considerations, the individual’s ability to complete activities of daily living and instrumental activities of daily living, and to assess additional services needed.
    not selected
6. Process for Level of Care Evaluation/Reevaluation: Per 42 CFR §441.303(c)(1), describe the process for evaluating waiver applicants for their need for the level of care under the waiver. If the reevaluation process differs from the evaluation process, describe the differences:

   Character Count: out of 12000
   The Form 817b is the form that documents that the individual meets the level of care criteria and other program eligibility requirements. This form is completed when evaluating applicants for their need for the level of care under the Waiver. The Comprehensive Brain Injury Assessment (CBIA) is the assessment tool used to assess the applicant, including this individual’s diagnoses, ADL, IADL, medical and social needs. The CBIA is completed at the initial level of care evaluation, as well as each year for the reevaluation.
7. Reevaluation Schedule. Per 42 CFR §441.303(c)(4), reevaluations of the level of care required by a participant are conducted no less frequently than annually according to the following schedule (select one):
    Every three months
    Every six months
    Every twelve months
    Other schedule
   Specify the other schedule:

   Character Count: out of 4000

   Every 12 months or more often as needed.
    not selected
8. Qualifications of Individuals Who Perform Reevaluations. Specify the qualifications of individuals who perform reevaluations (select one):
    The qualifications of individuals who perform reevaluations are the same as individuals who perform initial evaluations.
    The qualifications are different.
   Specify the qualifications:

   Character Count: out of 6000
    not selected
9. Procedures to Ensure Timely Reevaluations. Per 42 CFR §441.303(c)(4), specify the procedures that the State employs to ensure timely reevaluations of level of care (specify):

   Character Count: out of 6000
   The Utah Systems for Tracking Eligibility, Planning, and Services (USTEPS), developed and maintained by the Division of Services for People with Disabilities, provides from an automated tickler “to do” message to be sent to the support coordinator at the beginning of the month in which a re-evaluation is due.
10. Maintenance of Evaluation/Reevaluation Records. Per 42 CFR §441.303(c)(3), the State assures that written and/or electronically retrievable documentation of all evaluations and reevaluations are maintained for a minimum period of 3 years as required in 45 CFR §92.42. Specify the location(s) where records of evaluations and reevaluations of level of care are maintained:

    Character Count: out of 6000
    Electronically retrievable documentation of all evaluations and re-evaluations are maintained within the USTEPS system. To assure documents are retrievable, standard data back-up procedures employed with the UTSTEPS datebase include: The DSPD_USTEPS_PROD_DB is backed up from Sybase database to a disk dump at 10:30 PM every night. The UNIX backup occur on the following schedule (these are backups to tape) Monthly Full on 1st of each month – copies are retained on and off site for 3 years.

Appendix B: Evaluation/Reevaluation of Level of Care

Quality Improvement: Level of Care

1. Methods for Discovery: Level of Care Assurance/Sub-assurances
   1. Sub-Assurances:

      1. Sub-assurance: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future.

         Performance Measures

         For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

         Performance Measure: A level of care is conducted for all participants who meet DSPD service criteria and request to be served by the ABI Waiver. Data Source (Select one): Other If 'Other' is selected, specify: DSPD records Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: Participants who are admitted to the ABI Waiver meet nursing facility level of care. Data Source (Select one): Other If 'Other' is selected, specify: Participant records, CBIA, and Form 817b. Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: OA: At a minimum every two years. SMA: At a minimum every five years. Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify: OA: At a minimum every two years. SMA: At a minimum every five years.

      2. Sub-assurance: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver.

         Performance Measures

         For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

         Performance Measure: Level of Care is reviewed at least annually. Data Source (Select one): Other If 'Other' is selected, specify: Participant Records, CBIA, and 817b. Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: OA: At a minimum every two years. SMA: At a minimum every five years. Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify: OA: At a minimum every two years. SMA: At a minimum every five years.

         Performance Measure: Participant’s level of care is re-evaluated whenever a substantial change in health status occurs to determine if the change constitutes continued nursing facility level of care. Data Source (Select one): Other If 'Other' is selected, specify: Participant records, CBIA, and Participant interviews. Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: OA: At a minimum every two years. SMA: At a minimum every five years. Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify: OA: At a minimum every two years. SMA: At a minimum every five years.

      3. Sub-assurance: The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant level of care.

         Performance Measures

         For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

         Performance Measure: A qualified ABI support coordinator performs initial evaluations and re-evaluations of Level of Care. Data Source (Select one): Other If 'Other' is selected, specify: Participant records and DSPD Records. Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: OA: At a minimum every two years. SMA: At a minimum every five years. Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify: OA: At a minimum every two years. SMA: At a minimum every five years.

         Performance Measure: Level of care is documented on form 817b. Data Source (Select one): Other If 'Other' is selected, specify: Participant records and Form 817b. Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: At a minimum every two years. Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify: At a minimum every two years.

         Performance Measure: Form 927 “Home and Community-Based Waiver Referral Form” is used to document the effective date of the applicant’s Medicaid eligibility determination and the effective date of the applicant’s level of care eligibility determination. Data Source (Select one): Other If 'Other' is selected, specify: Participant records and Form 927. Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: OA: At a minimum every two years. SMA: At a minimum every five years. Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify: OA: At a minimum every two years. SMA: At a minimum every five years.

   2. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
      Character Count: out of 6000
      Individuals who request services from DSPD are screened for level of care for all waivers, ranked according to critical needs assessment process and placed on the waiting list. When the individual is taken off the waiting list, the ABI Support Coordinator/Intake Worker (ABISC) determines if the individual needs services from the ABI Waiver. For all individuals who have been taken off the waiting list and continue to require services, an initial evaluation for level of care is conducted by the ABISC. The SMA conducts an annual review of the ABI program for each of the five Waiver years. At a minimum, one comprehensive review will be conducted during this five year cycle. The comprehensive review will include participant and provider interviews. The other annual reviews will be focused reviews. The criteria for the focused reviews will be determined from DSPD and SMA review findings as well as other issues that develop during the review year. The sample size for each review will be sufficient to provide a confidence level equal to 95% and a confidence interval equal to 5.
2. Methods for Remediation/Fixing Individual Problems
   1. Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.
      Character Count: out of 6000
      Individual issues identified by the SMA and DSPD that affect the health and welfare of individual participants are addressed immediately. Issues that are less immediate are corrected within designated time frames and are documented through the SMA final review report. When the SMA determines that an issue is resolved, notification is provided and documentation is maintained by the SMA.
   2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)

      Responsible Party (check each that applies):	Frequency of data aggregation and analysis (check each that applies):
      State Medicaid Agency	Weekly
      Operating Agency	Monthly
      Sub-State Entity	Quarterly
      Other Specify:	Annually
      	Continuously and Ongoing
      	Other Specify: OA: At a minimum every two years. SMA: At a minimum every five years.

3. Timelines
   When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Financial Accountability that are currently non-operational.

    No

    Yes

    not selected
   Please provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

B-7: Freedom of Choice

1. Procedures. Specify the State's procedures for informing eligible individuals (or their legal representatives) of the feasible alternatives available under the waiver and allowing these individuals to choose either institutional or waiver services. Identify the form(s) that are employed to document freedom of choice. The form or forms are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
   Character Count: out of 12000
   Freedom of Choice is documented on the Form 818b. Freedom of choice procedures: 1. When an individual is determined eligible for waiver services, the individual and the individual’s legal representative, if applicable, will be informed of the alternatives available under the waiver and offered the choice of institutional care (NF) or home and community-based care. A copy of the DSPD publication AN INTRODUCTORY GUIDE—Division of Services for People with Disabilities (hereafter referred to as the Guide), which describes the array of services and supports available in Utah including nursing facilities and the HCBS Waiver program, is given to each individual applying for waiver services. 2. The support coordinator will offer the choice of waiver services only if: a. The individual's needs assessment indicates the services the individual requires, including waiver services, are available in the community. b. The individual support plan has been agreed to by all parties. c. The health and safety of the individual can be adequately protected in relation to the delivery of waiver services and supports. 3. Once the individual has chosen home and community-based waiver services, the choice has been documented by the support coordinator, and the individual has received a copy of the Guide, subsequent review of choice of program will only be required at the time a substantial change in the enrollee’s condition results in a change in the individual support plan. It is, however, the individual’s option to choose institutional (NF) care at any time during the period they are in the waiver. 4. The waiver enrollee, and the individual’s legal representative if applicable, will be given the opportunity to choose the providers of waiver services identified on the individual support plan if more than one qualified provider is available to render the services. The individual’s choice of providers will be documented in the individual’s support plan. 5. The agency will provide an opportunity for a fair hearing, under 42 CFR Part 431, subpart E, to beneficiaries who are not given the choice of home or community-based services as an alternative to the institutional care specified for this request, or who are denied the waiver service(s) of their choice or the waiver provider(s) of their choice.
2. Maintenance of Forms. Per 45 CFR §92.42, written copies or electronically retrievable facsimiles of Freedom of Choice forms are maintained for a minimum of three years. Specify the locations where copies of these forms are maintained.
   Character Count: out of 4000
   The Freedom of Choice form, 818b, is maintained by the individual support coordinator in hard copy format.

Appendix B: Participant Access and Eligibility

B-8: Access to Services by Limited English Proficiency Persons

Appendix C: Participant Services

C-1: Summary of Services Covered (1 of 2)

1. Waiver Services Summary. List the services that are furnished under the waiver in the following table. If case management is not a service under the waiver, complete items C-1-b and C-1-c:

   Service Type	Service
   Statutory Service	ABI Waiver Support Coordination
   Statutory Service	Day Supports
   Statutory Service	Homemaker
   Statutory Service	Residential Habilitation
   Statutory Service	Respite
   Statutory Service	Supported Employment
   Extended State Plan Service	Occupational Therapy Extended State Plan
   Extended State Plan Service	Physical Therapy Extended State Plan
   Extended State Plan Service	Speech-Language Services Extended State Plan
   Supports for Participant Direction	Consumer Preparation Services
   Supports for Participant Direction	Financial Management Services
   Other Service	Behavior Consultation I
   Other Service	Behavior Consultation II
   Other Service	Behavior Consultation Service III
   Other Service	Chore Services
   Other Service	Cognitive Retraining Services
   Other Service	Companion Services
   Other Service	Environmental Adaptations - Home
   Other Service	Environmental Adaptations - Vehicle
   Other Service	Extended Living Supports
   Other Service	Living Start-Up Costs
   Other Service	Personal Budget Assistance
   Other Service	Personal Emergency Response System
   Other Service	Professional Medication Monitoring
   Other Service	Specialized Medical Equipment/Supplies/Assistive Technology - Purchase
   Other Service	Specialized Medical Equipment/Supplies/Assistive Technology- Monthly Fee
   Other Service	Supported Living
   Other Service	Transportation Services (non-medical)