Persons with mental illnesses. For each subgroup, the age range of the persons served by the waiver? Yes No That the target groups align with the levels of care specified in Item 1-F of the Application (Module 1). Yes No Are the waiver target group or groups sufficiently well-defined to permit the B-1-b: Additional determination that an individual meets the target group criteria? Yes No Criteria (See waiver instructions for Note: For IP designation the waiver targets only individuals who live with their full explanation of families, in their own private residence, or in a living arrangement where fewer additional criteria.) than four persons unrelated to the proprietor reside. B-1-c: Transition of When the waiver does not provide for the continuation of services to waiver Individuals Affected by participants beyond the age limit specified in the waiver, are there transition Maximum Age Limit planning procedures that link affected participants to another waiver or other services and supports that provide continuity of services in the community to the extent feasible? Yes No B-2: Individual Cost Limit Analyst Notes When the waiver imposes a cost limit that is lower than the cost of institutional B-2-a: Individual Cost services, is the limit based on sound analysis and rationale that within the Limit amount of the limit, the health and welfare of the waiver target population will be assured post entrance to the waiver? Yes No When the limit is expressed as an absolute dollar limit, does the waiver describe how the limit will be adjusted during the period in which the waiver is in effect? Yes No When a waiver imposes an individual cost limit, it is applied uniformly and fairly to all potentially eligible individuals. Yes No Do the procedures take into account the full range of supports that the B-2-b: Method of person requires in the community and include notification of the opportunity to Implementation of the request a Fair Hearing if enrollment is denied? Yes No Individual Cost (Complete only when the state applies any cost limit) B-2-c: Participant Does the waiver: Safeguards
Persons with mental illnesses. For each subgroup, the age range of the persons served by the waiver? Yes No That the target groups align with the levels of care specified in Item 1-F of the Application (Module 1). Yes No B-1-b: Additional Criteria (See waiver instructions for full explanation of additional criteria.) Are the waiver target group or groups sufficiently well-defined to permit the determination that an individual meets the target group criteria? Yes No Note: For IP designation the waiver targets only individuals who live with their families, in their own private residence, or in a living arrangement where fewer than four persons unrelated to the proprietor reside. B-1-c: Transition of Individuals Affected by Maximum Age Limit When the waiver does not provide for the continuation of services to waiver participants beyond the age limit specified in the waiver, are there transition planning procedures that link affected participants to another waiver or other services and supports that provide continuity of services in the community to the extent feasible? Yes No B-2: Individual Cost Limit Analyst Notes B-2-a: Individual Cost Limit When the waiver imposes a cost limit that is lower than the cost of institutional services, is the limit based on sound analysis and rationale that within the amount of the limit, the health and welfare of the waiver target population will be assured post entrance to the waiver? Yes No When the limit is expressed as an absolute dollar limit, does the waiver describe how the limit will be adjusted during the period in which the waiver is in effect? Yes No When a waiver imposes an individual cost limit, it is applied uniformly and fairly to all potentially eligible individuals. Yes No B-2-b: Method of Implementation of the Individual Cost (Complete only when the state applies any cost limit) Do the procedures take into account the full range of supports that the person requires in the community and include notification of the opportunity to request a Fair Hearing if enrollment is denied? Yes No B-2-c: Participant Safeguards Does the waiver:
CMSInstrumentforReviewingHCBSWaiverApplications-January2015.docx