Is Factor D’ greater than or equal to Factor G’? Yes No J-2-c-iii: Factor G If No, does the state provide an explanation for this? Yes No Derivation Is Factor D’ developed through sampling a comparable population? Yes No J-2-c-iv: Factor G’ If Yes, has the state provided information on the process used and how the D’ Derivation value was derived? Yes No Is the for the Factor G estimate fully documented, evidence-based, and appropriately justified? Yes No Are any deviations from CMS-372(S) data adequately explained, justified, and documented? Yes No Is the basis for the Factor G’ estimate fully documented, evidence-based, and appropriately justified? The projected first year G’ value should not deviate substantially from previous year trends unless the state has altered its Medicaid program. Yes No Are any deviations from CMS-372(S) data adequately explained, justified, and documented? Yes No For Non-Concurrent Waivers: J-2-d: Estimate of Factor Is the unit of service identified for each service? Yes No D Does the estimated number of units per user reflect the estimated ALOS rather than the potential maximum number of service units that a participant may J-2-d-i: Estimate of Factor utilize? Yes No D Non-Concurrent – Waiver For when there are services paid outside the capitation Concurrent Waivers, rate, has the state calculated: J-2-d-ii: Estimate of The total of all waiver costs? Yes No Factor D Concurrent – The subtotal for services paid within the capitation rate? Yes No §1915(b)/§1915(c) Waivers The subtotal for services paid outside the rate? Yes No The average cost per unduplicated participant for all waiver services? Yes No The average costs for services paid within and outside the capitation rate? Yes No
J-2-c-iii: Factor G Derivation J-2-c-iv: Factor G’ Derivation Is Factor D’ greater than or equal to Factor G’? Yes No If No, does the state provide an explanation for this? Yes No Is Factor D’ developed through sampling a comparable population? Yes No If Yes, has the state provided information on the process used and how the D’ value was derived? Yes No Is the for the Factor G estimate fully documented, evidence-based, and appropriately justified? Yes No Are any deviations from CMS-372(S) data adequately explained, justified, and documented? Yes No Is the basis for the Factor G’ estimate fully documented, evidence-based, and appropriately justified? The projected first year G’ value should not deviate substantially from previous year trends unless the state has altered its Medicaid program. Yes No Are any deviations from CMS-372(S) data adequately explained, justified, and documented? Yes No J-2-d: Estimate of Factor D J-2-d-i: Estimate of Factor D – Non-Concurrent Waiver J-2-d-ii: Estimate of Factor D – Concurrent §1915(b)/§1915(c) Waivers For Non-Concurrent Waivers: Is the unit of service identified for each service? Yes No Does the estimated number of units per user reflect the estimated ALOS rather than the potential maximum number of service units that a participant may utilize? Yes No For Concurrent Waivers, when there are services paid outside the capitation rate, has the state calculated: The total of all waiver costs? Yes No The subtotal for services paid within the capitation rate? Yes No The subtotal for services paid outside the rate? Yes No The average cost per unduplicated participant for all waiver services? Yes No The average costs for services paid within and outside the capitation rate? Yes No
CMSInstrumentforReviewingHCBSWaiverApplications-January2015.docx