1. Request Information (2 of 3)

6. Level(s) of Care. This waiver is requested in order to provide home and community-based waiver services to individuals who, but for the provision of such services, would require the following level(s) of care, the costs of which would be reimbursed under the approved Medicaid State plan (check each that applies):
   Hospital
   Select applicable level of care

    Hospital as defined in 42 CFR §440.10

   If applicable, specify whether the State additionally limits the waiver to subcategories of the hospital level of care:

   Character Count: out of 6000

    Inpatient psychiatric facility for individuals age 21 and under as provided in42 CFR §440.160

    not selected
   Nursing Facility
   Select applicable level of care

    Nursing Facility As defined in 42 CFR §440.40 and 42 CFR §440.155

   If applicable, specify whether the State additionally limits the waiver to subcategories of the nursing facility level of care:

   Character Count: out of 6000

    Institution for Mental Disease for persons with mental illnesses aged 65 and older as provided in 42 CFR §440.140

    not selected
   Intermediate Care Facility for the Mentally Retarded (ICF/MR) (as defined in 42 CFR §440.150)
   If applicable, specify whether the State additionally limits the waiver to subcategories of the ICF/MR level of care:

   Character Count: out of 6000

1. Request Information (3 of 3)

7. Concurrent Operation with Other Programs. This waiver operates concurrently with another program (or programs) approved under the following authorities
   Select one:
    Not applicable
    Applicable
   Check the applicable authority or authorities:

   Services furnished under the provisions of §1915(a)(1)(a) of the Act and described in Appendix I

   Waiver(s) authorized under §1915(b) of the Act.

   Specify the §1915(b) waiver program and indicate whether a §1915(b) waiver application has been submitted or previously approved:

   Character Count: out of 6000

   Specify the §1915(b) authorities under which this program operates (check each that applies):

   §1915(b)(1) (mandated enrollment to managed care)

   §1915(b)(2) (central broker)

   §1915(b)(3) (employ cost savings to furnish additional services)

   §1915(b)(4) (selective contracting/limit number of providers)

   A program operated under §1932(a) of the Act.

   Specify the nature of the State Plan benefit and indicate whether the State Plan Amendment has been submitted or previously approved:

   Character Count: out of 6000

   A program authorized under §1915(i) of the Act.

   A program authorized under §1915(j) of the Act.

   A program authorized under §1115 of the Act.

   Specify the program:

   Character Count: out of 6000

   Not applicable
    not selected
8. Dual Eligiblity for Medicaid and Medicare.
   Check if applicable:
   This waiver provides services for individuals who are eligible for both Medicare and Medicaid.

2. Brief Waiver Description

3. Components of the Waiver Request

The waiver application consists of the following components. Note: Item 3-E must be completed.

1. Waiver Administration and Operation. Appendix A specifies the administrative and operational structure of this waiver.

2. Participant Access and Eligibility. Appendix B specifies the target group(s) of individuals who are served in this waiver, the number of participants that the State expects to serve during each year that the waiver is in effect, applicable Medicaid eligibility and post-eligibility (if applicable) requirements, and procedures for the evaluation and reevaluation of level of care.

3. Participant Services. Appendix C specifies the home and community-based waiver services that are furnished through the waiver, including applicable limitations on such services.

4. Participant-Centered Service Planning and Delivery. Appendix D specifies the procedures and methods that the State uses to develop, implement and monitor the participant-centered service plan (of care).

5. Participant-Direction of Services. When the State provides for participant direction of services, Appendix E specifies the participant direction opportunities that are offered in the waiver and the supports that are available to participants who direct their services. (Select one):
    Yes. This waiver provides participant direction opportunities. Appendix E is required.

    No. This waiver does not provide participant direction opportunities. Appendix E is not required.

    not selected

6. Participant Rights. Appendix F specifies how the State informs participants of their Medicaid Fair Hearing rights and other procedures to address participant grievances and complaints.

7. Participant Safeguards. Appendix G describes the safeguards that the State has established to assure the health and welfare of waiver participants in specified areas.

8. Quality Improvement Strategy. Appendix H contains the Quality Improvement Strategy for this waiver.

9. Financial Accountability. Appendix I describes the methods by which the State makes payments for waiver services, ensures the integrity of these payments, and complies with applicable federal requirements concerning payments and federal financial participation.

10. Cost-Neutrality Demonstration. Appendix J contains the State's demonstration that the waiver is cost-neutral.

4. Waiver(s) Requested

1. Comparability. The State requests a waiver of the requirements contained in §1902(a)(10)(B) of the Act in order to provide the services specified in Appendix C that are not otherwise available under the approved Medicaid State plan to individuals who: (a) require the level(s) of care specified in Item 1.F and (b) meet the target group criteria specified in Appendix B.
2. Income and Resources for the Medically Needy. Indicate whether the State requests a waiver of §1902(a)(10)(C)(i)(III) of the Act in order to use institutional income and resource rules for the medically needy (select one):
    Not Applicable

    No

    Yes

    not selected
3. Statewideness. Indicate whether the State requests a waiver of the statewideness requirements in §1902(a)(1) of the Act (select one):

   No

   Yes

   If yes, specify the waiver of statewideness that is requested (check each that applies):

   Geographic Limitation. A waiver of statewideness is requested in order to furnish services under this waiver only to individuals who reside in the following geographic areas or political subdivisions of the State.

   Specify the areas to which this waiver applies and, as applicable, the phase-in schedule of the waiver by geographic area:

   Character Count: out of 6000

   The IRIS waiver is intended to provide an alternative to Family Care and Medicaid State Plan Services such as BadgerCare and Senior Care. Therefore, implementation is synchronized with long-term care reform statewide expansion. Long-term Care Reform is rolling out on a regional basis which will be complete in the next two years. People are given the choice to enroll in Family Care or IRIS as they transition from the current waivers, are taken off the waitlist, or in instances where wait list have been eliminated, upon eligiblity determination. Participants in IRIS continue to have access to the Medicaid card services (fee for service) to obtain needed medical or health related services such as Personal Care; Physical, Occupational, Speech Therapies; Mental Health treatment Services; and Durable Medical Equipment they need as these services are not included within this waiver As of December 31, 2010, this waiver will be operational in the following counties in Wisconsin: Ashland Barron Bayfield Buffalo Burnett Calumet Chippewa Clark Columbia Crawford Dodge Douglas Dunn Eau Claire Fond du Lac Green Green Lake Iron Jackson Jefferson Juneau Kenosha La Crosse Lafayette Langlade Lincoln Manitowoc Marathon Marquette Milwaukee Monroe Outagamie Ozaukee Pepin Pierce Polk Portage Price Racine Richland Rusk St. Croix Sauk Sawyer Sheboygan Trempealeau Vernon Walworth Washburn Washington Waukesha Waupaca Waushara Winnebago Wood DHS anticipates expansion of Family Care to residents of the remainder of Wisconsin's counties during the State's July 1, 2013 - June 30, 2015 budget biennium. Counties (15) remaining to transition to Family Care during this time period include: Adams Brown Dane Door Florence Forest Kewaunee Marinette Menominee Oconto Oneida Rock Shawano Taylor Vilas

   Limited Implementation of Participant-Direction. A waiver of statewideness is requested in order to make participant-direction of services as specified in Appendix E available only to individuals who reside in the following geographic areas or political subdivisions of the State. Participants who reside in these areas may elect to direct their services as provided by the State or receive comparable services through the service delivery methods that are in effect elsewhere in the State.

   Specify the areas of the State affected by this waiver and, as applicable, the phase-in schedule of the waiver by geographic area:

   Character Count: out of 6000

5. Assurances

1. Health & Welfare: The State assures that necessary safeguards have been taken to protect the health and welfare of persons receiving services under this waiver. These safeguards include:

   1. As specified in Appendix C, adequate standards for all types of providers that provide services under this waiver;

   2. Assurance that the standards of any State licensure or certification requirements specified in Appendix C are met for services or for individuals furnishing services that are provided under the waiver. The State assures that these requirements are met on the date that the services are furnished; and,

   3. Assurance that all facilities subject to §1616(e) of the Act where home and community-based waiver services are provided comply with the applicable State standards for board and care facilities as specified in Appendix C.

2. Financial Accountability. The State assures financial accountability for funds expended for home and community-based services and maintains and makes available to the Department of Health and Human Services (including the Office of the Inspector General), the Comptroller General, or other designees, appropriate financial records documenting the cost of services provided under the waiver. Methods of financial accountability are specified in Appendix I.

3. Evaluation of Need: The State assures that it provides for an initial evaluation (and periodic reevaluations, at least annually) of the need for a level of care specified for this waiver, when there is a reasonable indication that an individual might need such services in the near future (one month or less) but for the receipt of home and community based services under this waiver. The procedures for evaluation and reevaluation of level of care are specified in Appendix B.

4. Choice of Alternatives: The State assures that when an individual is determined to be likely to require the level of care specified for this waiver and is in a target group specified in Appendix B, the individual (or, legal representative, if applicable) is:

   1. Informed of any feasible alternatives under the waiver; and,

   2. Given the choice of either institutional or home and community based waiver services. Appendix B specifies the procedures that the State employs to ensure that individuals are informed of feasible alternatives under the waiver and given the choice of institutional or home and community-based waiver services.

5. Average Per Capita Expenditures: The State assures that, for any year that the waiver is in effect, the average per capita expenditures under the waiver will not exceed 100 percent of the average per capita expenditures that would have been made under the Medicaid State plan for the level(s) of care specified for this waiver had the waiver not been granted. Cost-neutrality is demonstrated in Appendix J.

6. Actual Total Expenditures: The State assures that the actual total expenditures for home and community-based waiver and other Medicaid services and its claim for FFP in expenditures for the services provided to individuals under the waiver will not, in any year of the waiver period, exceed 100 percent of the amount that would be incurred in the absence of the waiver by the State's Medicaid program for these individuals in the institutional setting(s) specified for this waiver.

7. Institutionalization Absent Waiver: The State assures that, absent the waiver, individuals served in the waiver would receive the appropriate type of Medicaid-funded institutional care for the level of care specified for this waiver.

8. Reporting: The State assures that annually it will provide CMS with information concerning the impact of the waiver on the type, amount and cost of services provided under the Medicaid State plan and on the health and welfare of waiver participants. This information will be consistent with a data collection plan designed by CMS.

9. Habilitation Services. The State assures that prevocational, educational, or supported employment services, or a combination of these services, if provided as habilitation services under the waiver are: (1) not otherwise available to the individual through a local educational agency under the Individuals with Disabilities Education Act (IDEA) or the Rehabilitation Act of 1973; and, (2) furnished as part of expanded habilitation services.

10. Services for Individuals with Chronic Mental Illness. The State assures that federal financial participation (FFP) will not be claimed in expenditures for waiver services including, but not limited to, day treatment or partial hospitalization, psychosocial rehabilitation services, and clinic services provided as home and community-based services to individuals with chronic mental illnesses if these individuals, in the absence of a waiver, would be placed in an IMD and are: (1) age 22 to 64; (2) age 65 and older and the State has not included the optional Medicaid benefit cited in 42 CFR §440.140; or (3) age 21 and under and the State has not included the optional Medicaid benefit cited in 42 CFR § 440.160.

7. Contact Person(s)

1. The Medicaid agency representative with whom CMS should communicate regarding the waiver is:

   Last Name:
   First Name:
   Title:
   Agency:
   Address:
   Address 2:
   City:
   State:	Wisconsin
   Zip:
   Phone:	Ext: TTY
   Fax:
   E-mail:

2. If applicable, the State operating agency representative with whom CMS should communicate regarding the waiver is:

   Last Name:
   First Name:
   Title:
   Agency:
   Address:
   Address 2:
   City:
   State:	Wisconsin
   Zip:
   Phone:	Ext: TTY
   Fax:
   E-mail:

Attachment #1: Transition Plan

Additional Needed Information (Optional)

Appendix A: Waiver Administration and Operation

7. Distribution of Waiver Operational and Administrative Functions. In the following table, specify the entity or entities that have responsibility for conducting each of the waiver operational and administrative functions listed (check each that applies):
   In accordance with 42 CFR §431.10, when the Medicaid agency does not directly conduct a function, it supervises the performance of the function and establishes and/or approves policies that affect the function. All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. Note: More than one box may be checked per item. Ensure that Medicaid is checked when the Single State Medicaid Agency (1) conducts the function directly; (2) supervises the delegated function; and/or (3) establishes and/or approves policies related to the function.

   Function	Medicaid Agency	Contracted Entity
   Participant waiver enrollment
   Waiver enrollment managed against approved limits
   Waiver expenditures managed against approved levels
   Level of care evaluation
   Review of Participant service plans
   Prior authorization of waiver services
   Utilization management
   Qualified provider enrollment
   Execution of Medicaid provider agreements
   Establishment of a statewide rate methodology
   Rules, policies, procedures and information development governing the waiver program
   Quality assurance and quality improvement activities

Appendix A: Waiver Administration and Operation

Quality Improvement: Administrative Authority of the Single State Medicaid Agency

1. Methods for Discovery: Administrative Authority
   The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.

   1. Performance Measures

      For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

      For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

      Performance Measure: Number and percent of required ICA reports that were submitted to the SMA per contract requirements. Numerator/Denominator: Number of ICA reports submitted per contract requirements over the number of required reports. Data Source (Select one): Other If 'Other' is selected, specify: Reports to SMA from IRIS Consultant Agency per contract. Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percent of required FSA reports that were submitted to the SMA per contract requirements. Numerator/Denominator: Number of FSA reports submitted per contract requirements over the number of required reports. Data Source (Select one): Other If 'Other' is selected, specify: Reports provided from the FSA per contract. Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percent of new enrollees who had a level of care determination completed by the ADRC that indicates an eligible level of care prior to waiver enrollment. Numerator/Denominator: Number of new enrollees during designated time period who had an eligible LOC determined prior to start date over number of new enrollees during the designated time period. Data Source (Select one): Other If 'Other' is selected, specify: Long-Term Care Functional Screen data and Enrollment data Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percent of annual eligibility redeterminations that were conducted by the ICA or ADRC within 365 days of the participant's last LOC determination. Numerator/Denominator: Number of participants whose most recent screen is older than 365 days on the last day of the designated period over the number of participants on the final day of the designated period. Data Source (Select one): Other If 'Other' is selected, specify: Long-Term Care Functional Screen and Enrollment data Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percent of initial service plans that were developed and approved in accordance with Waiver timelines (within 62 days of referral date). Numerator/Denominator: Number of service plans developed and approved within 62 days over the total number of service plans developed within the designated time period. Data Source (Select one): Other If 'Other' is selected, specify: ICA Service Plan data Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: ICA Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: ICA Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percent of participants who received services within the approved individual budget allocation, as verfied in a retrospective review. Numerator/Denominator: Number of participants reviewed who received services within the approved individual budget allocation over number of plans reviewed. Data Source (Select one): Record reviews, on-site If 'Other' is selected, specify: Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 95% Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percent of IRIS Consultant Agency screeners who are qualifed and certified to conduct level of care screenings using the Long-Term Care Functional Screen. Numerator/Denominator: Number of ICA certified ICA screeners over total number of ICA screeners. Data Source (Select one): Other If 'Other' is selected, specify: ICA screener report submitted to SMA Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: ICA Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percent of IRIS Consultant Agency screeners who pass the Inter-Rater Reliability test. Numerator/Denominator: Number of ICA screeners who pass the IRRT over the number of ICA screeners who take the IRRT. Data Source (Select one): Other If 'Other' is selected, specify: Inter-rater reliability test results Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify: Biennially

      Performance Measure: Number and percent of recent service plans (annual or updated plan) that were approved prior to implementation of services. Numerator/Denominator: Number of most recent service plans approved over of the number of service plans reviewed. Data Source (Select one): Record reviews, on-site If 'Other' is selected, specify: Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 95% Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percent of new providers for which the FSA ensured that the provider had a signed Medicaid provider agreement prior to furnishing services. Numerator/Denominator: Number of providers on the FSA payroll that have signed Medicaid provider agreements over the number of licensed/certified providers on the FSA payroll. Data Source (Select one): Other If 'Other' is selected, specify: FSA reports Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: FSA Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: FSA Annually Continuously and Ongoing Other Specify:

   2. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
      Character Count: out of 6000
      The performance measures in this section related to administrative authority will ensure that the IRIS Consultant Agency, Financial Services Agency, or ADRC implements program operations as indicated in their contract with DHS. Performance measures within other appendices in this application will also be used to ensure administrative oversight in the implementation of program operations, policies and process as indicated in the waiver program and Department requirements, but are not duplicated in this section. Additional discovery methods related to administrative oversight include issues that arise in the implementation of program operations that are identified by contracted agency (ICA, FSA) or through discovery methods employed by other sections within the Department related to its oversight of related program operations such as LOC determination and referral process by ADRCs, and Encounter data reporting. The FSA submits monthly reports to the SMA which are used for monitoring the performance of the contracted agency in meeting contract expectations and waiver requirements. Some of these reports provide data for performance measures while others provide information for monitoring contract expectations. If concerns are noted through this discovery process, DHS the SMA follows up on the concern with the FSA and ensures that remediation occurs. If the nature of the concern/issue reflects a systems issue, then a corrective action plan is established. Additionally, the FSA conducts internal QA following each payment/payroll period (bi-monthly) using a sample of transactions to ensure it is accurately performing steps in the payment process- the FSA provides the SMA with a report on the results of this QA activity and action steps to correct any errors.
2. Methods for Remediation/Fixing Individual Problems
   1. Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.
      Character Count: out of 6000
      The DHS works with its contracted agencies to correct any issues discovered through administrative oversight activities. The Department holds monthly meetings with its contracted agencies, ICA and FSA, to discuss information related to quality issues, program operations and the remediation of those issues. These meetings are documented through meeting minutes and include information related to the issue discussed and decisions related to solutions. The contracted agencies are responsible for correcting any individual issues discovered. The Department may also require immediate remedial action and impose corrective action plans to address these issues. The DLTC IRIS QM team collects information to document that the appropriate actions have occurred. Individual issues related to LOC determinations that are conducted by ADRCs prior to enrollment are addressed in collaboration with the Office of Resource Center Development (ORCD). Quality oversight of LOC determinations are a centralized function within the Department. Individual issues related to timeliness of initial screens are addressed by ORCD. Annual LOC redeterminations and change in condition screens will be conducted by the IRIS Consultant Agency as it transitions this function from ADRC to ICA. Any individual issue related to these types of screens will be addressed by the IRIS Consultant Agency and ultimately DHS if resolution cannot be accomplished at the contracted agency level. Each year the Department renegotiates its contracts with these agencies. This provides an opportunity to add specifications to the contract. Additionally, DHS is able to require contract changes at any time within the existing contract structure.
   2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)

      Responsible Party (check each that applies):	Frequency of data aggregation and analysis (check each that applies):
      State Medicaid Agency	Weekly
      Operating Agency	Monthly
      Sub-State Entity	Quarterly
      Other Specify: ICA and FSA	Annually
      	Continuously and Ongoing
      	Other Specify:

3. Timelines
   When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Administrative Authority that are currently non-operational.

    No

    Yes

    not selected
   Please provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

B-1: Specification of the Waiver Target Group(s)

1. Target Group(s). Under the waiver of Section 1902(a)(10)(B) of the Act, the State limits waiver services to a group or subgroups of individuals. Please see the instruction manual for specifics regarding age limits. In accordance with 42 CFR §441.301(b)(6), select one waiver target group, check each of the subgroups in the selected target group that may receive services under the waiver, and specify the minimum and maximum (if any) age of individuals served in each subgroup:

   Target Group	Included	Target SubGroup	Minimum Age	Maximum Age
   				Maximum Age Limit	No Maximum Age Limit
   Aged or Disabled, or Both - General
   		Aged
   		Disabled (Physical)
   		Disabled (Other)
   Aged or Disabled, or Both - Specific Recognized Subgroups
   		Brain Injury
   		HIV/AIDS
   		Medically Fragile
   		Technology Dependent
   Mental Retardation or Developmental Disability, or Both
   		Autism
   		Developmental Disability
   		Mental Retardation
   Mental Illness
   		Mental Illness
   		Serious Emotional Disturbance
   not selected

2. Additional Criteria. The State further specifies its target group(s) as follows:

   Character Count: out of 12000

3. Transition of Individuals Affected by Maximum Age Limitation. When there is a maximum age limit that applies to individuals who may be served in the waiver, describe the transition planning procedures that are undertaken on behalf of participants affected by the age limit (select one):

   Not applicable. There is no maximum age limit

   The following transition planning procedures are employed for participants who will reach the waiver's maximum age limit.

   Specify:

   Character Count: out of 12000

   When people with disabilities reach age 65 years they will be transferred to the Elderly target group.

Appendix B: Participant Access and Eligibility

B-2: Individual Cost Limit (1 of 2)

1. Individual Cost Limit. The following individual cost limit applies when determining whether to deny home and community-based services or entrance to the waiver to an otherwise eligible individual (select one) Please note that a State may have only ONE individual cost limit for the purposes of determining eligibility for the waiver:
    No Cost Limit. The State does not apply an individual cost limit. Do not complete Item B-2-b or item B-2-c.
    Cost Limit in Excess of Institutional Costs. The State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed the cost of a level of care specified for the waiver up to an amount specified by the State. Complete Items B-2-b and B-2-c.

   The limit specified by the State is (select one)

    A level higher than 100% of the institutional average.

   Specify the percentage:

    Other

   Specify:

   Character Count: out of 6000

    not selected
    Institutional Cost Limit. Pursuant to 42 CFR 441.301(a)(3), the State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed 100% of the cost of the level of care specified for the waiver. Complete Items B-2-b and B-2-c.
    Cost Limit Lower Than Institutional Costs. The State refuses entrance to the waiver to any otherwise qualified individual when the State reasonably expects that the cost of home and community-based services furnished to that individual would exceed the following amount specified by the State that is less than the cost of a level of care specified for the waiver.

   Specify the basis of the limit, including evidence that the limit is sufficient to assure the health and welfare of waiver participants. Complete Items B-2-b and B-2-c.

   Character Count: out of 6000

   The cost limit specified by the State is (select one):

    The following dollar amount:

   Specify dollar amount:

   The dollar amount (select one)

    Is adjusted each year that the waiver is in effect by applying the following formula:

   Specify the formula:

   Character Count: out of 6000

    May be adjusted during the period the waiver is in effect. The State will submit a waiver amendment to CMS to adjust the dollar amount.

    not selected

    The following percentage that is less than 100% of the institutional average:

   Specify percent:

    Other:

   Specify:

   Character Count: out of 6000

    not selected
    not selected

Appendix B: Participant Access and Eligibility

B-2: Individual Cost Limit (2 of 2)

2. Method of Implementation of the Individual Cost Limit. When an individual cost limit is specified in Item B-2-a, specify the procedures that are followed to determine in advance of waiver entrance that the individual's health and welfare can be assured within the cost limit:
   Character Count: out of 12000
3. Participant Safeguards. When the State specifies an individual cost limit in Item B-2-a and there is a change in the participant's condition or circumstances post-entrance to the waiver that requires the provision of services in an amount that exceeds the cost limit in order to assure the participant's health and welfare, the State has established the following safeguards to avoid an adverse impact on the participant (check each that applies):
   The participant is referred to another waiver that can accommodate the individual's needs.
   Additional services in excess of the individual cost limit may be authorized.

   Specify the procedures for authorizing additional services, including the amount that may be authorized:

   Character Count: out of 12000
   Other safeguard(s)

   Specify:

   Character Count: out of 12000

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (1 of 4)

1. Unduplicated Number of Participants. The following table specifies the maximum number of unduplicated participants who are served in each year that the waiver is in effect. The State will submit a waiver amendment to CMS to modify the number of participants specified for any year(s), including when a modification is necessary due to legislative appropriation or another reason. The number of unduplicated participants specified in this table is basis for the cost-neutrality calculations in Appendix J:

   Table: B-3-a

   Waiver Year	Unduplicated Number of Participants
   Year 1
   Year 2
   Year 3
   Year 4
   Year 5

2. Limitation on the Number of Participants Served at Any Point in Time. Consistent with the unduplicated number of participants specified in Item B-3-a, the State may limit to a lesser number the number of participants who will be served at any point in time during a waiver year. Indicate whether the State limits the number of participants in this way: (select one):

   The State does not limit the number of participants that it serves at any point in time during a waiver year.

   The State limits the number of participants that it serves at any point in time during a waiver year.

   The limit that applies to each year of the waiver period is specified in the following table:

   Table: B-3-b

   Waiver Year	Maximum Number of Participants Served At Any Point During the Year
   Year 1
   Year 2
   Year 3
   Year 4
   Year 5

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (2 of 4)

3. Reserved Waiver Capacity. The State may reserve a portion of the participant capacity of the waiver for specified purposes (e.g., provide for the community transition of institutionalized persons or furnish waiver services to individuals experiencing a crisis) subject to CMS review and approval. The State (select one):

   Not applicable. The state does not reserve capacity.

   The State reserves capacity for the following purpose(s).

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (3 of 4)

4. Scheduled Phase-In or Phase-Out. Within a waiver year, the State may make the number of participants who are served subject to a phase-in or phase-out schedule (select one):

   The waiver is not subject to a phase-in or a phase-out schedule.

   The waiver is subject to a phase-in or phase-out schedule that is included in Attachment #1 to Appendix B-3. This schedule constitutes an intra-year limitation on the number of participants who are served in the waiver.

5. Allocation of Waiver Capacity.

   Select one:

   Waiver capacity is allocated/managed on a statewide basis.

   Waiver capacity is allocated to local/regional non-state entities.

   Specify: (a) the entities to which waiver capacity is allocated; (b) the methodology that is used to allocate capacity and how often the methodology is reevaluated; and, (c) policies for the reallocation of unused capacity among local/regional non-state entities:

   Character Count: out of 12000

   The role of the ADRC in managing waiver capacity is to manage the waitlist for enrollment during the initial three-year period of long-term care reform within a service area. The State of Wisconsin is moving away from local county agencies operating waivers to implement LTC Managed Care and Self-Directed Supports Waiver. The intent is to have this reform completed by 2013. As new counties are added to the reform effort all waiver participants in the legacy waivers (Community Integration and Community Options Waivers), as well as children aging-out of the Children’s Long-Term Support Waivers are offered the choice of long-term program and make the transition to the program of his or her choice without delay. Wisconsin then serves people on waiting lists in those areas on a first-come, first-serve basis until the wait lists are eliminated. After the waitlist is eliminated, typically three years after transition, entitlement begins. At this point, people who meet eligibility requirements receive options counseling and are immediately enrolled in the program of his or her choice and there will no longer an ADRC role in managing waiver capacity
6. Selection of Entrants to the Waiver. Specify the policies that apply to the selection of individuals for entrance to the waiver:
   Character Count: out of 12000
   All persons who are eligible for Medicaid home and community-based services under a s. 1915 (c) waiver will receive enrollment counseling through the Aging and Disability Resource Center. When a person is found to be functionally and financially eligible for a waiver program, the applicant receives counseling to choose between community care and institutional care. If the individual chooses to receive services in the home and community, he/she is asked to make a second choice among the managed care programs available in his/her area or the IRIS waiver. Based on the individual’s choice, he or she would be referred to the IRIS Consultant Agency for enrollment in IRIS. IRIS participants will be enrolled on a first-come, first-served basis until the number of unduplicated recipients specified in the waiver application is reached. Wisconsin has sufficient budget appropriations from the Legislature to cover the costs of services for the number of unduplicated recipients specified. Please refer to Appendix B-3 e. Allocation of Waiver Capacity above for details about rollout of statewide expansion for IRIS.

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served - Attachment #1 (4 of 4)

Appendix B: Participant Access and Eligibility

B-4: Eligibility Groups Served in the Waiver

1. 1. State Classification. The State is a (select one):
       §1634 State
       SSI Criteria State
       209(b) State
       not selected
   2. Miller Trust State.
      Indicate whether the State is a Miller Trust State (select one):
       No
       Yes
       Unknown
2. Medicaid Eligibility Groups Served in the Waiver. Individuals who receive services under this waiver are eligible under the following eligibility groups contained in the State plan. The State applies all applicable federal financial participation limits under the plan. Check all that apply:
   Eligibility Groups Served in the Waiver (excluding the special home and community-based waiver group under 42 CFR §435.217)
   Low income families with children as provided in §1931 of the Act
   SSI recipients
   Aged, blind or disabled in 209(b) states who are eligible under 42 CFR §435.121
   Optional State supplement recipients
   Optional categorically needy aged and/or disabled individuals who have income at:

   Select one:

    100% of the Federal poverty level (FPL)

    % of FPL, which is lower than 100% of FPL.

   Specify percentage:

    not selected
   Working individuals with disabilities who buy into Medicaid (BBA working disabled group as provided in §1902(a)(10)(A)(ii)(XIII)) of the Act)
   Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1902(a)(10)(A)(ii)(XV) of the Act)
   Working individuals with disabilities who buy into Medicaid (TWWIIA Medical Improvement Coverage Group as provided in §1902(a)(10)(A)(ii)(XVI) of the Act)
   Disabled individuals age 18 or younger who would require an institutional level of care (TEFRA 134 eligibility group as provided in §1902(e)(3) of the Act)
   Medically needy
   Medically needy in 209(b) States (42 CFR §435.330)
   Medically needy in 1634 States and SSI Criteria States (42 CFR §435.320, §435.322 and §435.324)
   Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver)

   Specify:

   Character Count: out of 6000

   All other mandatory and optional groups under the state plan are included.
   Special home and community-based waiver group under 42 CFR §435.217) Note: When the special home and community-based waiver group under 42 CFR §435.217 is included, Appendix B-5 must be completed
    No. The State does not furnish waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217. Appendix B-5 is not submitted.

    Yes. The State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217.

    not selected

   Select one and complete Appendix B-5.

    All individuals in the special home and community-based waiver group under 42 CFR §435.217

    Only the following groups of individuals in the special home and community-based waiver group under 42 CFR §435.217

    not selected

   Check each that applies:

   A special income level equal to:

   Select one:

    300% of the SSI Federal Benefit Rate (FBR)

    A percentage of FBR, which is lower than 300% (42 CFR §435.236)

   Specify percentage:

    A dollar amount which is lower than 300%.

   Specify dollar amount:

    not selected

   Aged, blind and disabled individuals who meet requirements that are more restrictive than the SSI program (42 CFR §435.121)

   Medically needy without spenddown in States which also provide Medicaid to recipients of SSI (42 CFR §435.320, §435.322 and §435.324)

   Medically needy without spend down in 209(b) States (42 CFR §435.330)

   Aged and disabled individuals who have income at:

   Select one:

    100% of FPL

    % of FPL, which is lower than 100%.

   Specify percentage amount:

    not selected

   Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver)

   Specify:

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (1 of 4)

In accordance with 42 CFR §441.303(e), Appendix B-5 must be completed when the State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217, as indicated in Appendix B-4. Post-eligibility applies only to the 42 CFR §435.217 group. A State that uses spousal impoverishment rules under §1924 of the Act to determine the eligibility of individuals with a community spouse may elect to use spousal post-eligibility rules under §1924 of the Act to protect a personal needs allowance for a participant with a community spouse.

1. Use of Spousal Impoverishment Rules. Indicate whether spousal impoverishment rules are used to determine eligibility for the special home and community-based waiver group under 42 CFR §435.217 (select one):

    Spousal impoverishment rules under §1924 of the Act are used to determine the eligibility of individuals with a community spouse for the special home and community-based waiver group.

   In the case of a participant with a community spouse, the State elects to (select one):

    Use spousal post-eligibility rules under §1924 of the Act.

   (Complete Item B-5-b (SSI State) and Item B-5-d)

    Use regular post-eligibility rules under 42 CFR §435.726 (SSI State) or under §435.735 (209b State)

   (Complete Item B-5-b (SSI State) . Do not complete Item B-5-d)

    not selected

    Spousal impoverishment rules under §1924 of the Act are not used to determine eligibility of individuals with a community spouse for the special home and community-based waiver group. The State uses regular post-eligibility rules for individuals with a community spouse.

   (Complete Item B-5-b (SSI State) . Do not complete Item B-5-d)

    not selected

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (2 of 4)

2. Regular Post-Eligibility Treatment of Income: SSI State.

   The State uses the post-eligibility rules at 42 CFR 435.726 for individuals who do not have a spouse or have a spouse who is not a community spouse as specified in §1924 of the Act. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the following allowances and expenses from the waiver participant's income:

   1. Allowance for the needs of the waiver participant (select one):

       The following standard included under the State plan

      Select one:

       SSI standard

       Optional State supplement standard

       Medically needy income standard

       The special income level for institutionalized persons

      (select one):

       300% of the SSI Federal Benefit Rate (FBR)

       A percentage of the FBR, which is less than 300%

      Specify the percentage:

       A dollar amount which is less than 300%.

      Specify dollar amount:

       not selected

       A percentage of the Federal poverty level

      Specify percentage:

       Other standard included under the State Plan

      Specify:

      Character Count: out of 36000

       not selected
       The following dollar amount

      Specify dollar amount: If this amount changes, this item will be revised.
       The following formula is used to determine the needs allowance:

      Specify:

      Character Count: out of 6000

      The basic needs allowance, indexed annually by the percentage increase in the state’s SSI-E payment; plus an allowance for employed individuals equal to the first 65 dollars of earned income and ½ of remaining earned income; plus special exempt income which includes court ordered support amounts (child or spousal support) and court ordered attorney and /or guardian fees; plus a special housing amount that includes housing costs over $350 per month. The total of these 4 allowances cannot exceed 300% of the SSI federal benefit.
       Other

      Specify:

      Character Count: out of 6000
       not selected

   2. Allowance for the spouse only (select one):

       Not Applicable
       The state provides an allowance for a spouse who does not meet the definition of a community spouse in §1924 of the Act. Describe the circumstances under which this allowance is provided:

      Specify:

      Character Count: out of 6000

      Specify the amount of the allowance (select one):

       SSI standard

       Optional State supplement standard

       Medically needy income standard

       The following dollar amount:

      Specify dollar amount: If this amount changes, this item will be revised.

       The amount is determined using the following formula:

      Specify:

      Character Count: out of 6000

       not selected
       not selected

   3. Allowance for the family (select one):

       Not Applicable (see instructions)
       AFDC need standard
       Medically needy income standard
       The following dollar amount:

      Specify dollar amount: The amount specified cannot exceed the higher of the need standard for a family of the same size used to determine eligibility under the State's approved AFDC plan or the medically needy income standard established under 42 CFR §435.811 for a family of the same size. If this amount changes, this item will be revised.
       The amount is determined using the following formula:

      Specify:

      Character Count: out of 6000
       Other

      Specify:

      Character Count: out of 6000
       not selected

   4. Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 §CFR 435.726:

      1. Health insurance premiums, deductibles and co-insurance charges
      2. Necessary medical or remedial care expenses recognized under State law but not covered under the State's Medicaid plan, subject to reasonable limits that the State may establish on the amounts of these expenses.

      Select one:

       Not Applicable (see instructions) Note: If the State protects the maximum amount for the waiver participant, not applicable must be selected.
       The State does not establish reasonable limits.
       The State establishes the following reasonable limits

      Specify:

      Character Count: out of 6000
       not selected

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (3 of 4)

3. Regular Post-Eligibility Treatment of Income: 209(B) State.

   Answers provided in Appendix B-4 indicate that you do not need to complete this section and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (4 of 4)

4. Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules

   The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care if it determines the individual's eligibility under §1924 of the Act. There is deducted from the participant’s monthly income a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the State Medicaid Plan.. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).

   1. Allowance for the personal needs of the waiver participant

      (select one):
       SSI standard
       Optional State supplement standard
       Medically needy income standard
       The special income level for institutionalized persons
       A percentage of the Federal poverty level

      Specify percentage:
       The following dollar amount:

      Specify dollar amount: If this amount changes, this item will be revised
       The following formula is used to determine the needs allowance:

      Specify formula:

      Character Count: out of 4000

      The basic needs allowance, indexed annually by the percentage increase in the state’s SSI-E payment; plus an allowance for employed individuals equal to the first 65 dollars of earned income and ½ of remaining earned income; plus special exempt income which includes court ordered support amounts (child or spousal support) and court ordered attorney and /or guardian fees; plus a special housing amount that includes housing costs over $350 per month. The total of these 4 allowances cannot exceed 300% of the SSI federal benefit.
       Other

      Specify:

      Character Count: out of 36000
       not selected

   2. If the allowance for the personal needs of a waiver participant with a community spouse is different from the amount used for the individual's maintenance allowance under 42 CFR §435.726 or 42 CFR §435.735, explain why this amount is reasonable to meet the individual's maintenance needs in the community.

      Select one:

       Allowance is the same
       Allowance is different.

      Explanation of difference:

      Character Count: out of 6000
       not selected

   3. Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 §CFR 435.726:

      1. Health insurance premiums, deductibles and co-insurance charges
      2. Necessary medical or remedial care expenses recognized under State law but not covered under the State's Medicaid plan, subject to reasonable limits that the State may establish on the amounts of these expenses.

      Select one:

       Not Applicable (see instructions) Note: If the State protects the maximum amount for the waiver participant, not applicable must be selected.
       The State does not establish reasonable limits.
       The State uses the same reasonable limits as are used for regular (non-spousal) post-eligibility.
       not selected

Appendix B: Participant Access and Eligibility

B-6: Evaluation/Reevaluation of Level of Care

1. Reasonable Indication of Need for Services. In order for an individual to be determined to need waiver services, an individual must require: (a) the provision of at least one waiver service, as documented in the service plan, and (b) the provision of waiver services at least monthly or, if the need for services is less than monthly, the participant requires regular monthly monitoring which must be documented in the service plan. Specify the State's policies concerning the reasonable indication of the need for services:

   1. Minimum number of services.

      The minimum number of waiver services (one or more) that an individual must require in order to be determined to need waiver services is:
   2. Frequency of services. The State requires (select one):
       The provision of waiver services at least monthly
       Monthly monitoring of the individual when services are furnished on a less than monthly basis

      If the State also requires a minimum frequency for the provision of waiver services other than monthly (e.g., quarterly), specify the frequency:

      Character Count: out of 4000
       not selected
2. Responsibility for Performing Evaluations and Reevaluations. Level of care evaluations and reevaluations are performed (select one):
    Directly by the Medicaid agency
    By the operating agency specified in Appendix A
    By an entity under contract with the Medicaid agency.

   Specify the entity:

   Character Count: out of 4000

   Initial Evaluations are performed by the local Aging and Disability Resource Centers. These initial LOC evaluations are conducted prior to any potential enrollee choosing a long-term care program. The ADRC has been performing re-evaluations until 2011. An implementation plan is in place from Jan-July 2011 to transition the responsibility for performing re-evaluations to the IRIS Consultant Agency. Re-evaluations of LOC will be performed by the IRIS Consultant Agency for all IRIS participants beginning in July 2011. The transition of this change related to annual recertifications will take place during 2011 and will be completed no later than 1/1/2012. The proposed timeline by county of participant residence is as follows: January 2011: Langlade and Milwaukee February 2011: Jefferson, Kenosha, Racine and Walworth March 2011: Dodge, Ozaukee, Washington and Waukesha April 2011: Dunn, Lincoln, Pepin, Pierce, and St. Croix May 2011: Chippewa, Clark, Eau Claire and Jackson June 2011: Calumet, Manitowoc and Winnebago July 2011: Fond du Lac, Outagamie and Sheboygan August 2011: Green Lake, Marathon, Marquette, Portage, Waupaca, Waushara and Wood September 2011: Buffalo, Juneau, La Crosse, Monroe and Trempealeau October 2011: Ashland, Barron, Bayfield, Burnett, Douglas, Iron, Polk, Price, Rusk, Sawyer and Washburn November 2011: Columbia, Crawford, Grant, Green, Iowa, Lafayette, Richland, Sauk and Vernon All new counties as part of expansion per the geographic limitations section will immediately have the IRIS Consultant Agency provide for annual recertification.
    Other
   Specify:

   Character Count: out of 4000
    not selected
3. Qualifications of Individuals Performing Initial Evaluation: Per 42 CFR §441.303(c)(1), specify the educational/professional qualifications of individuals who perform the initial evaluation of level of care for waiver applicants:

   Character Count: out of 6000
   Anyone who performs the Long Term Care Functional Screen, the web-based application/tool that determines a participant's level of care for eligibility determination (initial evaluations and re-evaluations), must meet the same certification and education/experience standards. The "screener" must be either a registered nurse or certified social worker in Wisconsin or have a 4 year Bachelor's degree in a related field, and have at a minimum one year of experience working with at least one of the long-term care target groups and/or specialized knowledge of the long term care target populations. Screeners must pass an on-line certification course through the Wisconsin School of Nursing Continuing Education web portal. No screener is granted access to the screen application until he or she has passed the online test that evaluates the understanding of content (knowledge) and the application of instructions (skills). Electronic records of these tests are created and maintained by the DHS. The records of screener qualifications employed by an ADRC are maintained by that ADRC. The Office of Resource Center Development (ORCD) conducts its own process to monitor and ensure that ADRC's employ screeners who meet qualifications and certification standards. ADRC screeners conduct initial evaluations for Level of Care prior to a person enrolling in any long-term care program and therefore this monitoring is outside the scope of the IRIS SDS Waiver. The IRIS Consultant Agency (ICA) ensures that the screeners it employs to conduct re-evaluations of Level of Care (annual and change-in-condition) meet qualifications and certifications which are maintained in their employee records. The ICA has a tracking mechanism in place that documents qualifications and certification standards. The ICA will provide a report to the SMA on an annual basis related to its screener qualifications. This report will be used as the data source for the performance measure under Administrative Authority related to screener qualifications.
4. Level of Care Criteria. Fully specify the level of care criteria that are used to evaluate and reevaluate whether an individual needs services through the waiver and that serve as the basis of the State's level of care instrument/tool. Specify the level of care instrument/tool that is employed. State laws, regulations, and policies concerning level of care criteria and the level of care instrument/tool are available to CMS upon request through the Medicaid agency or the operating agency (if applicable), including the instrument/tool utilized.

   Character Count: out of 12000
   The levels of care criteria are the same as the criteria for Medicaid reimbursement of nursing facility care in Wisconsin. The specific level of care for this waiver is nursing home level of care.
5. Level of Care Instrument(s). Per 42 CFR §441.303(c)(2), indicate whether the instrument/tool used to evaluate level of care for the waiver differs from the instrument/tool used to evaluate institutional level of care (select one):
    The same instrument is used in determining the level of care for the waiver and for institutional care under the State Plan.
    A different instrument is used to determine the level of care for the waiver than for institutional care under the State plan.

   Describe how and why this instrument differs from the form used to evaluate institutional level of care and explain how the outcome of the determination is reliable, valid, and fully comparable.

   Character Count: out of 12000

   The levels of care criteria are the same as the criteria for Medicaid reimbursement of care in nursing home level of care in Wisconsin. The specific level of care allowed is nursing home level of care. The level of care tool used is the Wisconsin Long-term Care Functional Screen. It can be administered by trained screeners other than registered nurses. The functional screen was developed with the registered nurses in the State Medicaid Agency who evaluate Physician Plans of Care to determine Medicaid eligibility for nursing home admission. It has been evaluated by the State Medicaid Agency and determined to be valid, reliable and to result in comparable level of care. On a biennial basis the Department conducts inter-rater reliability testing (IRRT) of all certified LTC FS screeners in Wisconsin. The test results are maintained by the Department. Any screener who does not pass the IRRT, the screener's employer receives notification with details about how to proceed to help screener get into compliance. If screener is unable to meet improvement expectations they would be de-certified
    not selected
6. Process for Level of Care Evaluation/Reevaluation: Per 42 CFR §441.303(c)(1), describe the process for evaluating waiver applicants for their need for the level of care under the waiver. If the reevaluation process differs from the evaluation process, describe the differences:

   Character Count: out of 12000
   Information used in level of care assessments for new enrollees is gathered by ADRC screeners during a face-to-face meeting with the participant using the State’s automated long-term care functional screen. When this information is entered into the functional screen tool, it applies the level of care criteria to issue a result for the individual. Information for annual reevaluations of level of care is gathered during a face-to-face meeting with staff at the ADRC using the same tool. The SMA will transition to the IRIS Consultant Agency completing reevaluations during the first year of waiver renewal. There after, this will continue to be an IRIS Consultant Agency requirement. A review of "ineligible" LOC determinations, which ensures that individuals are not inappropriately designated as ineligible is addressed through the following processes: •Screeners are instructed to call the Clinical Help Desk if a screen returns an unexpected result. The SMA Clinical Help Desk staff reviews the screen, element by element, with the screener, until both parties are satisfied that the screen was completed accurately. •Monthly queries are run on the database associated with the screen. This report pulls all screens completed during the preceding month. All of the screens (100%) that returned "ineligible" results are identified. The SMA Clinical staff then review the internal consistency and apparent completeness of each one of those screens. Patterns of ineligible submissions are noted and explored. This includes whether there are patterns specific to a screener or screen agency. All questionable screens are investigated and the SMA has the authority to order a screen to be repeated or revised as necessary to assure accuracy. •On an ongoing basis, every screen that is challenged, appealed or results in a complaint, is reviewed by the DHS Clinical Team for completeness and accuracy. The Clinical experts complete individual remediation to assure a proper result for individuals and track this information for trends to ensure continuous improvement of the process.
7. Reevaluation Schedule. Per 42 CFR §441.303(c)(4), reevaluations of the level of care required by a participant are conducted no less frequently than annually according to the following schedule (select one):
    Every three months
    Every six months
    Every twelve months
    Other schedule
   Specify the other schedule:

   Character Count: out of 4000
    not selected
8. Qualifications of Individuals Who Perform Reevaluations. Specify the qualifications of individuals who perform reevaluations (select one):
    The qualifications of individuals who perform reevaluations are the same as individuals who perform initial evaluations.
    The qualifications are different.
   Specify the qualifications:

   Character Count: out of 6000
    not selected
9. Procedures to Ensure Timely Reevaluations. Per 42 CFR §441.303(c)(4), specify the procedures that the State employs to ensure timely reevaluations of level of care (specify):

   Character Count: out of 6000
   Currently, the IRIS Consultant Agency is responsible to ensure the participant is referred to the ADRC to conduct an annual functional screen. The ADRC will provide a copy of the LTC Functional Screen for each participant to the ICA which will include the date of the screen. A new screen is required within 12 months of that date. The ICA maintains a tickler process to provide timely notice referring the participant to the ADRC for the annual functional screen, assisting the participant in making an appointment with the ADRC upon request. During the first year of waiver renewal, the SMA will transition this requirement to the IRIS Consultant Agency. Additionally, the SMA will use the automated long-term care functional screen database in comparison the Medicaid eligibility system (CARES) to ensure timely reevaluations of level of care. The level of care annual result is sent automatically to the CARES system. The Economic Support worker who recertifies Medicaid eligibility annually cannot complete this process unless there is a current (within the last 12 months) screen completed with a LOC result.
10. Maintenance of Evaluation/Reevaluation Records. Per 42 CFR §441.303(c)(3), the State assures that written and/or electronically retrievable documentation of all evaluations and reevaluations are maintained for a minimum period of 3 years as required in 45 CFR §92.42. Specify the location(s) where records of evaluations and reevaluations of level of care are maintained:

    Character Count: out of 6000
    All functional screens are maintained electronically by the SMA central office in its automated long-term care functional screen computer system. In addition, a hard copy of the functional screen level of care result is maintained in each participant’s record by the IRIS Consultant Agency. LTC FS Screener qualifications/certification is maintained in employee files at the agencies in which they are employed. The SMA maintains a central list of qualified screeners (who passed certification and IRRT). Screeners only gain access to this system after completing all required training and after the agency verifies the screener’s qualifications. As noted in the performance measure under Administrative Authority an annual screener qualification/certification report is submitted to the SMA annually.

Appendix B: Evaluation/Reevaluation of Level of Care

Quality Improvement: Level of Care

1. Methods for Discovery: Level of Care Assurance/Sub-assurances
   1. Sub-Assurances:

      1. Sub-assurance: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future.

         Performance Measures

         For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

         Performance Measure: Number and percent of new enrollees who had a level of care determination indicating an eligible level of care prior to receipt of services. Numerator/Denominator: Number of new enrollees during designated time period who do not have a completed LTCFS on record over number of new enrollees during the designated time period. Data Source (Select one): Other If 'Other' is selected, specify: Long-Term Care Functional Screen data and Enrollment data Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      2. Sub-assurance: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver.

         Performance Measures

         For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

         Performance Measure: Number and percent of waiver participants who received an annual redetermination of eligibility within 365 days of their of their last LOC evaluation. Numerator/Denominator: Number of participants whose most recent screen is older than 365 days on the last day of the designated period over the number of participants on the final day of the designated period. Data Source (Select one): Other If 'Other' is selected, specify: Long-Term Care Functional Screen data and Enrollment data Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      3. Sub-assurance: The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant level of care.

         Performance Measures

         For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
   2. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
      Character Count: out of 6000
      The Long Term Care Functional Screen (LTC FS) is a web-based application/tool that is used statewide to determine an individual’s level of care (LOC) and eligibility for multiple adult waiver programs, including IRIS. The quality and administrative oversight of the LTC FS is centralized within the Division of Long Term Care through a cross-unit team with Department staff members who are jointly responsible for ensuring that the quality standards for the LTC FS are consistently applied across programs, agencies, and screeners statewide. These standards include ensuring that screeners meet all required qualifications before being granted access to the web-based LTC FS for the purpose of conducting the functional eligibility and level of care determination, implementing inter-rater reliability testing (IRRT) to ensure screeners are applying the LTC FS criteria appropriately, and conducting quality review of screens at both the agency and individual screener levels. Other discovery activities the cross unit team performs through the use of LTC FS data include: monitoring timeliness of LTC FS, routine analysis of submitted screens and ad hoc studies, reviewing screens in which individuals were determined ineligible to ensure accuracy (checking for false negatives prior to enrollment in a specificied program), conducting desk review of the LTC FS at the agency level for ADRCs, Managed Care Organizations (MCOs) and the IRIS Consultant Agency. The desk reviews use a fixed sample of 30 records per agency. Desk reviews are conducted on a monthly basis. These reviews are performed viewing the on-line screen and look at screen scoring for comprehensiveness and consistency. The data and results from these activities are documented by this cross-unit team; this information is then shared internally and within DHS for information sharing and decision-making about remediation efforts across programs. Additionally, other performance measures related to LOC determinations are included under the Appendix A and not duplicated in this section. LTC FS Screener qualifications/certification is maintained in employee files at the agencies in which they are employed. The SMA maintains a central list of qualified screeners (who passed certification and IRRT). Screeners only gain access to this system after completing all required training and after the agency verifies the screener’s qualifications. As noted in the performance measure under Administrative Authority an annual screener qualification/certification report is submitted to the SMA annually. Performance Measures related to sub-assurance c can be found under Administrative Authority. There are 4 measures that evaluate the processes and instruments used in determining level of care. In addition, the SMA determined that it would not measure the number of false negatives/false positives as this quality assurance activity is conducted through a centralized SMA (DHS)process for LTC FS and is not exclusive of the IRIS program; it encompasses ALL adult LTC FS screens performed throughout the state for all programs and for screens conducted by an ADRC prior to a person's enrollment.
2. Methods for Remediation/Fixing Individual Problems
   1. Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.
      Character Count: out of 6000
      Quality issues or inaccuracies associated with individual LOC determinations are addressed through the correction of the LTC FS through edits or a rescreen as appropriate. These screens are updated by either an ADRC or ICA screener as necessary. Individual issues related to the screener qualifications and certification are addressed by the statewide inter-rater reliability testing (IRRT) developed by the Division of Long-Term Care. This IRRT is conducted on a biennial basis at the agency level. If an individual screener does not pass the initial IRRT, quality staff at the agency level will work with the screener to develop a corrective action plan and individualized remediation.
   2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)

      Responsible Party (check each that applies):	Frequency of data aggregation and analysis (check each that applies):
      State Medicaid Agency	Weekly
      Operating Agency	Monthly
      Sub-State Entity	Quarterly
      Other Specify:	Annually
      	Continuously and Ongoing
      	Other Specify:

3. Timelines
   When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Level of Care that are currently non-operational.

    No

    Yes

    not selected
   Please provide a detailed strategy for assuring Level of Care, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

B-7: Freedom of Choice

1. Procedures. Specify the State's procedures for informing eligible individuals (or their legal representatives) of the feasible alternatives available under the waiver and allowing these individuals to choose either institutional or waiver services. Identify the form(s) that are employed to document freedom of choice. The form or forms are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
   Character Count: out of 12000
   The Aging and Disability Resource Center (ADRC) has a conversation with the consumer about their personal situation and service needs. The ADRC may then offer a functional screen to each individual who may have a need for long-term care services. The functional screen automatically determines Level of Care and Functional eligibility for publicly funded LTC. The functional screen process must include a face-to-face interview with the recipient and/or his/her legal representative. If the person is determined to be eligible for an available long term care program, the ADRC would provide options counseling. During the options counseling process implemented, people are informed about their right to choose between institutional and home and community-based services and their options under the Family Care and IRIS waivers, including alternatives to the waiver programs (i.e. local community resources or use of Medicaid-fee-for-service). The ADRC documents that these choices were offered during options counseling and this documentation is maintained within the ADRC system. After the individual makes a decision, the ADRC staff assists the person with enrollment in his or her preferred program. Copies of the signed referral form are provided to the enrollee and retained by the ADRC, which then facilitates the enrollment process. Once a participant enrolls in IRIS, he or she is again informed about: 1.) the choice between institutional care and home/community based services 2.) the choice of waiver services, and 3.) the choice of providers during plan development during the initial plan development process. This was being documented on the Individual Support and Service Plan (ISSP) and verified by the participant or legal decision-makers signature. An improvement in this process is being made that will go into effect in April 2011. This information will no longer be on the person's individual support/service plan; instead it will be documented on a separate form. This new form documents that the IRIS Consultant discussed these choices with the participant and includes a review of other pertinent information such as Participant Rights and Responsibilities, Appeal Rights, and responsibility to inform IRIS Consultant/Agency about any reportable incident. This form will be implemented when a person is initially enrolled during the plan development process; and annually thereafter during the participant’s annual plan review. The participant will verify they were informed by signing the document which will be maintained in the participant’s record and will be verified during the SMA’s Record Review An individual may disenroll at any time, return to the ADRC for enrollment counseling and seek admission into Family Care or Medicaid fee for service.
2. Maintenance of Forms. Per 45 CFR §92.42, written copies or electronically retrievable facsimiles of Freedom of Choice forms are maintained for a minimum of three years. Specify the locations where copies of these forms are maintained.
   Character Count: out of 4000
   The Aging and Disability Resource Centers, which is responsible for conducting level of care assessment evaluations and for facilitating the eligibility determination and enrollment processes maintains documentation of the option counseling provided to potential enrollees about their choices and the IRIS Referral form that indicates a person chooses the IRIS program. The IRIS Consultant Agency maintains copies of the signed individual support and service plans that indicate choices are discussed for participants who enrolled prior to April 2011. Beginning April 2011 this information will be documented on a separate form as described in B-7a and maintained in the individual participant's record.

Appendix B: Participant Access and Eligibility

B-8: Access to Services by Limited English Proficiency Persons

Appendix C: Participant Services

C-1: Summary of Services Covered (1 of 2)

1. Waiver Services Summary. List the services that are furnished under the waiver in the following table. If case management is not a service under the waiver, complete items C-1-b and C-1-c:

   Service Type	Service
   Statutory Service	Adult Day Care
   Statutory Service	Daily Living Skills Training
   Statutory Service	Live-in Caregiver (42 CFR §441.303(f)(8))
   Statutory Service	Prevocational Services
   Statutory Service	Respite
   Statutory Service	Supported Employment
   Extended State Plan Service	Nursing Services
   Other Service	1-2 Bed Adult Family Home
   Other Service	3-4 Bed Adult Family Home
   Other Service	Adaptive Aids
   Other Service	CBRF
   Other Service	Communication Aids Vendors/Interpreter Services
   Other Service	Consumer Education and Training
   Other Service	Counseling and Therapeutic Services
   Other Service	Customized Goods and Services
   Other Service	Day Services
   Other Service	Home Delivered Meals
   Other Service	Home Modification
   Other Service	Housing Counseling
   Other Service	Personal Emergency Response System
   Other Service	Relocation - Housing Start Up and Related Utility Costs
   Other Service	Residential Care Apartment Complex
   Other Service	Specialized Medical Equipment and Supplies
   Other Service	Specialized Transportation 2
   Other Service	Specialized Transportation
   Other Service	Support Broker
   Other Service	Supportive Home Care
   Other Service	Vocational Futures Planning