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Emergency Preparedness and Response for Home and Community Based (HCBS) 1915(c) Waivers

Appendix K is a standalone appendix that may be utilized by states during emergency situations to request amendment to approved 1915(c) waivers. It includes actions that states can take under the existing Section 1915(c) home and community-based waiver authority in order to respond to an emergency.  Other activities may require the use of various other authorities such as the Section 1115 demonstrations or the Section 1135 authorities.  This appendix may be completed retroactively as needed by the state.

Appendix K Templates and Instructions

Approved COVID-19 Appendix K Documents

Note: Information on the underlying waivers can be found on the State Waiver List

State Approval Letter(s) Approved Appendix K
Alabama Approval Letter (PDF, 109.22 KB) Appendix K - AL 0001, 0391 Combined (PDF, 448.86 KB)
Appendix K - AL 0068, 0878, 0241, 0407 Combined (PDF, 551.24 KB)
Alaska Approval Letter (PDF, 108.77 KB) Appendix K - AK Combined (PDF, 277.94 KB)
Arizona Approval Letter (PDF, 446.73 KB)   AHCCCS 1115 Demonstration (1-W-00275/9) Appendix K (PDF, 444.29 KB)
Arkansas Approval Letter (PDF, 107.94 KB)

AR.0188 Appendix K (PDF, 100.7 KB)
Appendix K - AR 0195, 0400 Combined

California Approval Letter (PDF, 108.14 KB)  
Approval Letter 2 (PDF, 109.9 KB)  
CA.0139 Appendix K (PDF, 174.59 KB)
CA.0141 Appendix K (PDF, 161.82 KB)
CA.0183 Appendix K (PDF, 163.69 KB)
CA.0336 Appendix K (PDF, 127.16 KB)
CA.0431 Appendix K (PDF, 134.94 KB)
Appendix K - CA Combined (PDF, 100.33 KB)
Appendix K - CA Combined 2 (PDF, 101.95 KB)
Colorado

Approval Letter (PDF, 134.69 KB)  
Approval Letter 2 (PDF, 108.87 KB)
Approval Letter 3 (PDF, 109.59 KB)
Approval Letter 4 (PDF, 110.26 KB)

Appendix K - CO Combined 1 (PDF, 454.8 KB)
Appendix K - CO Combined 2 (PDF, 181.06 KB)
Appendix K - CO Combined 3 (PDF, 102.67 KB)
Appendix K - CO Combined 4 (PDF, 88.39 KB)

Connecticut Approval Letter (PDF, 136.49 KB)

CT.0140 Appendix K (PDF, 100.12 KB)
CT.0301 Appendix K (PDF, 106.33 KB)
CT.0302 Appendix K (PDF, 136.46 KB)
CT.0653 Appendix K (PDF, 149.76 KB)
CT.0993 Appendix K (PDF, 130.22 KB)
CT.1085 Appendix K (PDF, 134.04 KB)
CT.4110 Appendix K (PDF, 98.49 KB)
Appendix K - CT 0081, 0426, 0437 Combined (PDF, 142.2 KB)

Delaware Approval Letter (PDF, 107.92 KB) DE.0009 Appendix K (PDF, 155.42 KB)
District of Columbia Approval Letter (PDF, 108.05 KB) Appendix K - DC Combined (PDF, 167.77 KB)
Florida Approval Letter (PDF, 108.18 KB) FL.0867 Appendix K (PDF, 129.66 KB)
FL.0962 Appendix K (PDF, 126.88 KB)
Appendix K - FL 40166, 40205 Combined (PDF, 98.13 KB)
Georgia Approval Letter (PDF, 108.93 KB)   Appendix K - GA 0112, 4170 Combined (PDF, 222.57 KB)
Appendix K - GA 0323, 0175 Combined (PDF, 348.24 KB)
Hawaii Approval Letter (PDF, 107.53 KB)  
Approval Letter 2 (PDF, 103.76 KB)  
Approval Letter 3 (PDF, 107.66 KB)  
HI.0013 Appendix K (PDF, 237.55 KB)
HI.0013 Appendix K 2 (PDF, 160.46 KB)
HI.0013 Appendix K 3 (PDF, 71.02 KB)
Illinois Approval Letter (PDF, 110.18 KB) Appendix K - IL Combined (PDF, 361.38 KB)
Indiana Approval Letter (PDF, 109.39 KB) IN.0378 Appendix K (PDF, 460.73 KB)
IN.0387 Appendix K (PDF, 317.3 KB)
Appendix K - IN 0210, 4197 Combined (PDF, 179.48 KB)
Iowa Approval Letter (PDF, 132.86 KB)   Appendix K - IA Combined (PDF, 159.21 KB)
Kansas Approval Letter (PDF, 135.35 KB)  
Approval Letter 2 (PDF, 109.1 KB)  
Appendix K - KS Combined (PDF, 194.96 KB)
Appendix K - KS Combined 2 (PDF, 206.79 KB)
Kentucky Approval Letter (PDF, 108.93 KB) Appendix K - KY Combined (PDF, 133.28 KB)
Louisiana Approval Letter (PDF, 109.14 KB)   LA.0121 Appendix K (PDF, 130.2 KB)
LA.0866 Appendix K (PDF, 114.06 KB)
LA.0889 Appendix K (PDF, 102.83 KB)
Appendix K - LA 0401, 0472, 0361, 0453 Combined (PDF, 119.24 KB)
Maine Approval Letter (PDF, 109.53 KB)
Approval Letter 2 (PDF, 108.13 KB)
Appendix K - ME Combined (PDF, 168.57 KB)
ME.0467 Appendix K (PDF, 111.73 KB)
Maryland Approval Letter (PDF, 131.91 KB)
Approval Letter 2 (PDF, 104.84 KB)
Appendix K - MD 1466, 1506, 0023 Combined (PDF, 783.1 KB)
Appendix K - MD 0339, 40198, 0265, 40118, 0645 Combined (PDF, 208.6 KB)
Massachusetts Approval Letter (PDF, 110.12 KB) Appendix K - MA Combined (PDF, 154.43 KB)
Minnesota Approval Letter (PDF, 108.19 KB)
Approval Letter 2 (PDF, 108.07 KB)
Approval Letter 3 (PDF, 130.96 KB)
Approval Letter 4 (PDF, 106.52 KB)
Appendix K - MN Combined (PDF, 154.31 KB)
Appendix K - MN Combined 2 (PDF, 113.86 KB)
Appendix K - MN Combined 3 (PDF, 105.96 KB)
MN.0166 Appendix K (PDF, 93.89 KB)
Mississippi

Approval Letter (PDF, 108.03 KB)
Approval Letter 2 (PDF, 105.7 KB)

MS.0225 Appendix K (PDF, 149.03 KB)
MS.0272 Appendix K (PDF, 109.02 KB)
MS.0282 Appendix K (PDF, 123.56 KB)
MS.0355 Appendix K (PDF, 101.33 KB)
MS.0366 Appendix K (PDF, 129.63 KB)
Missouri Approval Letter (PDF, 109.51 KB) Appendix K - MO 0026, 1021, 0346 Combined (PDF, 139.14 KB)
Appendix K - MO 0178, 0404, 0841, 4185 Combined (PDF, 355.49 KB)
MO.0197 Appendix K (PDF, 168.36 KB)
MO.40190 Appendix K (PDF, 121.71 KB)
Montana Approval Letter (PDF, 108.61 KB) Appendix K - MT Combined (PDF, 141.71 KB)
Nebraska  Approval Letter (PDF, 138.89 KB) NE.0187 Appendix K (PDF, 195.96 KB)
NE.0394 Appendix K (PDF, 272.07 KB)
NE.4154 Appendix K (PDF, 325.43 KB)
NE.40199 Appendix K (PDF, 98.18 KB)
Nevada Approval Letter (PDF, 180.94 KB) Appendix K - NV Combined (PDF, 156.72 KB)
New Hampshire Approval Letter (PDF, 132.1 KB) Appendix K - NH Combined (PDF, 1.2 MB)
New Mexico Approval Letter (PDF, 108.16 KB)
Approval Letter 2 (PDF, 128.5 KB)
Appendix K - NM Combined (PDF, 283.48 KB)
Appendix K - NM Combined 2 (PDF, 183.89 KB)
New York Approval Letter (PDF, 107.5 KB)
Approval Letter (PDF, 106.61 KB)
NY.0238 Appendix K (PDF, 724.39 KB)
Appendix K - NY 0444, 0269 Combined (PDF, 122.64 KB)
North Carolina Approval Letter (PDF, 107.06 KB)  
Approval Letter 2 (PDF, 107.71 KB)  
NC.0132 Appendix K (PDF, 429.64 KB)
NC.0423 Appendix K (PDF, 178.93 KB)
NC.1326 Appendix K (PDF, 174.86 KB)
NC.4141 Appendix K (PDF, 395.88 KB)
NC.0423 Appendix K 2 (PDF, 259.74 KB)
NC.1326 Appendix K 2 (PDF, 210.82 KB)
North Dakota Approval Letter (PDF, 109.3 KB) ND.0037 Appendix K (PDF, 295.85 KB)
ND.0273 Appendix K (PDF, 166.71 KB)
ND.0568 Appendix K (PDF, 171.77 KB)
ND.0834 Appendix K (PDF, 160.87 KB)
ND.0842 Appendix K (PDF, 147.58 KB)
Ohio Approval Letter (PDF, 109.06 KB) Appendix K - OH 0231, 0380, 0877 Combined (PDF, 324.19 KB)
Appendix K - OH 0446, 0337, 1035, 0198 Combined (PDF, 405.89 KB)
Oklahoma Approval Letter (PDF, 108.57 KB)
Approval Letter 2 (PDF, 108 KB)
OK.0256 Appendix K (PDF, 353.79 KB)
OK.0343 Appendix K (PDF, 204.87 KB)
OK.0351 Appendix K (PDF, 193.48 KB)
OK.0811 Appendix K (PDF, 239.06 KB)
Appendix K - OK 0179, 0399 Combined (PDF, 262.53 KB)
Appendix K - OK 0179, 0343, 0399 Combined (PDF, 127.06 KB)
Oregon Approval Letter (PDF, 132.45 KB)
Approval Letter 2 (PDF, 108.44 KB)
OR.0185 Appendix K (PDF, 171.45 KB)
Appendix K - OR 0117, 0375, 0565, 40193, 40194 Combined (PDF, 177.89 KB) <
Appendix K - OR Combined 2 (PDF, 126.31 KB)
Pennsylvania

Approval Letter (PDF, 108.98 KB)  
Approval Letter 2 (PDF, 133.84 KB)
Approval Letter 3 (PDF, 104.41 KB)

PA.0147 Appendix K (PDF, 109.36 KB)
PA.0235 Appendix K (PDF, 95.33 KB)
PA.0235 Appendix K - Amended (PDF, 134.49 KB)
PA.0324 Appendix K -  Amended
PA.0354 Appendix K (PDF, 104.42 KB)
PA.0386 Appendix K (PDF, 95.01 KB)
PA.0386 Appendix K - Amended (PDF, 134.48 KB)
PA.0593 Appendix K (PDF, 153.82 KB)
PA.1486 Appendix K (PDF, 108.87 KB)

Rhode Island Approval Letter (PDF, 394.77 KB)

Comprehensive 1115 Demonstration (11-W-00242/1) (PDF, 74.83 KB)

South Carolina Approval Letter (PDF, 109.55 KB) SC.0675 Appendix K (PDF, 103.71 KB)
Appendix K - SC 0237, 0676, 0284 Combined (PDF, 206.56 KB)
Appendix K - SC 0405, 0186, 40181 Combined (PDF, 96.65 KB)
South Dakota Approval Letter (PDF, 108.38 KB)  
Approval Letter 2 (PDF, 107.93 KB)  
SD.0044 Appendix K (PDF, 101.73 KB)
SD.0189 Appendix K (PDF, 141.22 KB)
SD.0264 Appendix K (PDF, 187.56 KB)
Tennessee Approval Letter (PDF, 108.04 KB) Appendix K - TN Combined (PDF, 426.88 KB)
Utah Approval Letter (PDF, 110.25 KB) Appendix K - UT Combined (PDF, 297.15 KB)
Virginia Approval Letter (PDF, 108.9 KB)
Approval Letter 2 (PDF, 209.45 KB)
Appendix K - VA Combined (PDF, 197.17 KB)
Appendix K - VA Combined 2 (PDF, 298.44 KB)
Washington

Approval Letter (PDF, 135.43 KB)  (03/19/2020)
Approval Letter (PDF, 106.87 KB) (03/23/2020)
Approval Letter (PDF, 131.36 KB) (04/21/2020)

WA.0049 Appendix K (PDF, 145.83 KB)
WA.0049 Appendix K (PDF, 141.59 KB)
WA.0409 Appendix K (PDF, 574.07 KB)
WA.0410 Appendix K (PDF, 598.92 KB)
WA.0411 Appendix K (PDF, 496.94 KB)
WA.0443 Appendix K (PDF, 135.29 KB)
WA.1086 Appendix K (PDF, 109.36 KB)
WA.1086 Appendix K (PDF, 333.67 KB)
WA.1186 Appendix K (PDF, 702.08 KB)
WA.40669 Appendix K (PDF, 461.7 KB)

West Virginia Approval Letter (PDF, 104.05 KB)

WV.0133 Appendix K (PDF, 79.35 KB)
WV.0134 Appendix K (PDF, 77.36 KB)
WV.0876 Appendix K (PDF, 77.08 KB)
WV.1646 Appendix K (PDF, 105.09 KB)

Wisconsin Approval Letter (PDF, 107.36 KB)
Approval Letter 2 (PDF, 138.68 KB)
WI.0414 Appendix K (PDF, 123.8 KB)
WI.0367 Appendix K (PDF, 224.02 KB)
WI.0484 Appendix K (PDF, 146.73 KB)
Wyoming  Approval Letter (PDF, 132.27 KB)
Approval Letter 2 (PDF, 107.69 KB)
Approval Letter 3 (PDF, 107.53 KB)
Approval Letter 4 (PDF, 135.93 KB)
Appendix K - WY Combined (PDF, 159.48 KB)
Appendix K - WY 1060, 1061 Combined (PDF, 166.15 KB)
WY.0451 Appendix K (PDF, 102.86 KB)
WY.0236 Appendix K (PDF, 159 KB)