Yes No Is the frequency of oversight specified? Yes No A-3: Use of Contracted Entities Analyst Notes When waiver operational and administrative activities are performed by contracted entities, does the waiver specify the types of entities that perform such activities and describe the types of activities that are performed by each type of entity? Yes No N/A A-4: Role of Local/Regional Non-State Entities Analyst Notes Do local/regional non-state entities perform waiver operational and (Complete only when states administrative functions at the local or regional level? This includes Public use Local/Regional (e.g., counties or other entities under control of elected officials) or Agencies Entities to provide Non-Governmental Entities (e.g., AAA, county developmental disabilities waiver services.) authorities). Yes No Does the state specify the waiver operational activities/functions that local/regional non-state entities perform? Yes No Does the state describe the nature of the non-state entities? Yes No A-5: Responsibility for Assessment of Performance of Contracted and/or Local/Regional Non-State Analyst Notes Entities Does the state agency specify the state agency or agencies responsible for (Complete only when the assessing the performance of contracted and/or local/regional non-state entities state uses contracted (Item conducting waiver operational and administrative functions? Yes No A-3 is checked) and/or local/regional non-state entities (Item A-4 is checked)) A-6: Assessment Methods and Frequency Analyst Notes Does the state describe: (Complete only when the The methods that are used to assess the performance of contracted and/or state uses contracted (Item non-state entities to ensure that they perform assigned waiver A-3 is checked) and/or operational and administrative functions are in accordance with waiver local/regional non-state requirements? Yes No entities (Item A-4 is checked))
Yes No Is the frequency of oversight specified? Yes No A-3: Use of Contracted Entities Analyst Notes When waiver operational and administrative activities are performed by contracted entities, does the waiver specify the types of entities that perform such activities and describe the types of activities that are performed by each type of entity? Yes No N/A A-4: Role of Local/Regional Non-State Entities Analyst Notes (Complete only when states use Local/Regional Entities to provide waiver services.) Do local/regional non-state entities perform waiver operational and administrative functions at the local or regional level? This includes Public Agencies (e.g., counties or other entities under control of elected officials) or Non-Governmental Entities (e.g., AAA, county developmental disabilities authorities). Yes No Does the state specify the waiver operational activities/functions that local/regional non-state entities perform? Yes No Does the state describe the nature of the non-state entities? Yes No A-5: Responsibility for Assessment of Performance of Contracted and/or Local/Regional Non-State Entities Analyst Notes (Complete only when the state uses contracted (Item A-3 is checked) and/or local/regional non-state entities (Item A-4 is checked)) Does the state agency specify the state agency or agencies responsible for assessing the performance of contracted and/or local/regional non-state entities conducting waiver operational and administrative functions? Yes No A-6: Assessment Methods and Frequency Analyst Notes (Complete only when the state uses contracted (Item A-3 is checked) and/or local/regional non-state entities (Item A-4 is checked)) Does the state describe: The methods that are used to assess the performance of contracted and/or non-state entities to ensure that they perform assigned waiver operational and administrative functions are in accordance with waiver requirements? Yes No
CMSInstrumentforReviewingHCBSWaiverApplications-January2015.docx