Does the apportionment method used provide that only the participant’s additional rent and food costs associated with having a live-in caregiver are reimbursed? Yes No Are only the incurred by the participant reimbursed? Yes No Does the method of making payment for a live-in caregiver the payment through the provider but clearly provide for the reimbursement of the participant? Yes No I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing Analyst Notes Does the state impose a co-payment or similar charge upon participants for I-7-a: State Requirement for waiver services? Yes No Co-pays If Yes, Are the types of charges imposed on waiver participants specified? Yes I-7-a Co-pay –i: No Arrangement Do the groups subject to co-payment comply with the applicable provisions I-7-a -ii. Participants Subject of 42 CFR §447.53? Notably, that children up to the age of 18 (or up to age to Co-Pay Charges for 19, 20, or 21 at the state’s option) are excluded from co-payment. Yes No Waiver Services Does the state specify for each waiver services for which a co-payment is made, the amount and basis of the charge? The amount of the co-payment I-7-a-iii. Amount of Co-Pay charge may not exceed the schedule of allowable charges contained in 42 Charges for Waiver Services CFR §447.54(a)(3) that establishes maximum charges based on the cost of a service. Yes No I-7-a-iv. Cumulative Does the state specify whether there is a cumulative maximum amount of Maximum Charges co-payments that may be charged to a waiver participant? Yes No Does the impose a premium, enrollment fee, or similar cost-sharing I-7-b: Other State arrangement on waiver participants? Yes No Requirements for Cost If Yes, the state has specified: Sharing The type of cost sharing arrangement? Yes No The amount of the cost-sharing charge? Yes No How the amount of the charge is related to total gross family income in 42 CFR §447.52? Yes No The groups of participants who are subject to cost-sharing and the groups excluded this must comply with 42 CFR §447.53 (no children)? Yes – No
Does the apportionment method used provide that only the participant’s additional rent and food costs associated with having a live-in caregiver are reimbursed? Yes No Are only the incurred by the participant reimbursed? Yes No Does the method of making payment for a live-in caregiver the payment through the provider but clearly provide for the reimbursement of the participant? Yes No I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing Analyst Notes I-7-a: State Requirement for Co-pays I-7-a –i: Co-pay Arrangement I-7-a -ii. Participants Subject to Co-Pay Charges for Waiver Services I-7-a-iii. Amount of Co-Pay Charges for Waiver Services I-7-a-iv. Cumulative Maximum Charges Does the state impose a co-payment or similar charge upon participants for waiver services? Yes No If Yes, Are the types of charges imposed on waiver participants specified? Yes No Do the groups subject to co-payment comply with the applicable provisions of 42 CFR §447.53? Notably, that children up to the age of 18 (or up to age 19, 20, or 21 at the state’s option) are excluded from co-payment. Yes No Does the state specify for each waiver services for which a co-payment is made, the amount and basis of the charge? The amount of the co-payment charge may not exceed the schedule of allowable charges contained in 42 CFR §447.54(a)(3) that establishes maximum charges based on the cost of a service. Yes No Does the state specify whether there is a cumulative maximum amount of co-payments that may be charged to a waiver participant? Yes No I-7-b: Other State Requirements for Cost Sharing Does the impose a premium, enrollment fee, or similar cost-sharing arrangement on waiver participants? Yes No If Yes, the state has specified: The type of cost sharing arrangement? Yes No The amount of the cost-sharing charge? Yes No How the amount of the charge is related to total gross family income in 42 CFR §447.52? Yes No The groups of participants who are subject to cost-sharing and the groups excluded – this must comply with 42 CFR §447.53 (no children)? Yes No
CMSInstrumentforReviewingHCBSWaiverApplications-January2015.docx