conferred when participant direction opportunities are subject to a waiver of statewideness. 5. Assurances Analyst Refer to the Application for a complete description of the assurances. No response required. 6. Additional Requirements Analyst Notes Refer to the Application for a complete description of waiver requirements. 6-A: Service Plan No response required. 6-B: Inpatients No response required. No response required. 6-C: Room and Board 6-D: Access to Services No response required. 6-E: Free Choice of No response required. Provider 6-F: FFP Limitation No response required. No response required. 6-G: Fair Hearing 6-H: Quality Management No response required. 6-I: Public Input Does the state describe how it secures public input into the waiver development? Yes No 6-J: Notice to Tribal No response required. Governments 6-K: Limited English No response required. Proficiency Persons 7. Contact Person(s) Analyst Notes 7-A: State Medicaid Does the indicate who CMS should communicate regarding the waiver? Agency Representatives Yes No 7-B: Operating Agency Does the state indicate who CMS should communicate regarding the waiver? Representative Yes No N/A Note: (Only complete if the state The first line of communication between CMS and a state regarding a has indicated that the waiver waiver application is through State Medicaid agency. will be administered by a State agency (as provided in
conferred when participant direction opportunities are subject to a waiver of statewideness. 5. Assurances Refer to the Application for a complete description of the assurances. Analyst No response required. 6. Additional Requirements Refer to the Application for a complete description of waiver requirements. Analyst Notes 6-A: Service Plan No response required. 6-B: Inpatients No response required. 6-C: Room and Board No response required. 6-D: Access to Services No response required. 6-E: Free Choice of Provider No response required. 6-F: FFP Limitation No response required. 6-G: Fair Hearing No response required. 6-H: Quality Management No response required. 6-I: Public Input Does the state describe how it secures public input into the waiver development? Yes No 6-J: Notice to Tribal Governments No response required. 6-K: Limited English Proficiency Persons No response required. 7. Contact Person(s) Analyst Notes 7-A: State Medicaid Agency Representatives Does the indicate who CMS should communicate regarding the waiver? Yes No 7-B: Operating Agency Representative (Only complete if the state has indicated that the waiver will be administered by a State agency (as provided in Does the state indicate who CMS should communicate regarding the waiver? Yes No N/A Note: The first line of communication between CMS and a state regarding a waiver application is through State Medicaid agency.
CMSInstrumentforReviewingHCBSWaiverApplications-January2015.docx