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CMS Requests More Information in Review of Consolidated MR Waiver
March 23, 2005

Pennsylvania’s Department of Public Welfare (DPW) has received a request for additional information from the federal Centers for Medicare and Medicaid Services (CMS) regarding the state’s renewal for the Consolidated Home and Community-Based Services Waiver for Individuals with Mental Retardation. Clarification is requested to assure that the waiver conforms to statutory and regulatory requirements. Information is requested regarding the following:

  • Federal regulation 42 CFR 431.10(e)(3) specifies that if other state or local agencies perform services for the Medicaid agency, they must not have the authority to change or disapproved any administration decisions of the agency. CMS believes the county MH/MR programs are operating counter to the provisions of this regulation.
  • Assurances that necessary services are provided to waiver participants by periodically reviewing the plans of care to ensure that services are furnished that are consistent with the identified needs of the individual. CMS requests copies of policies and procedures authorizing assurance that county MH/MR programs promptly revise service plans and authorize funding for provision of services.
  • In order to respond to the change in need for waiver participants, funds must be set aside by county MH/MR programs or DPW to pay for additional services required by the changing need. CMS requests copies of policies and procedures for monitoring the needs of waiver participants and adjusting service plans. This must include the state’s procedures to assure that insufficient financial resources are not an impediment.
  • A state may assign the task of developing individual program plans to other entities but the ultimate responsibility for the program plan content and control of funding must rest with the Medicaid agency. CMS’s review shows no indication that the ultimate approval authority rests with DPW.
  • Each provider agency must enter into an agreement with the Medicaid agency (42 CFR 431.107) and have established rules and practices for qualifying and enrolling providers in the waiver program. These polices must permit all providers meeting the provider standards to enter into a provider agreement and to furnish waiver services throughout Pennsylvania. CMS requests details on the provider qualifications, and how county MH/MR programs and "program funding" arrangements do not interfere with the enrollment of providers or with participant’s choice.

CMS also requested additional information regarding the state’s practices on rate setting and cost neutrality. Details are requested on DPW’s polices to:

  • Assure that provider rates are established by a standard rate setting methodology that assures access and comparability of services across the state.
  • Describe the department’s authority and polices to resolve any disputes between the county MH/MR program and providers about payment issues.
  • Describes policy and oversight of supplemental payments such as excess service credits.
  • On the issue of costs, CMS notes that the costs of waiver, institutional and state plan services do not reflect increases due to inflation or other adjustments over the five-year term of the renewal. Justification is requested regarding the absence of cost of living increases.

DPW has until April 30 to respond. For additional information contact Linda Drummond at PCPA.

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