Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. The CMS Review Process


On a periodic basis, CMS requires states to submit evidence that demonstrates their active monitoring of their waivers, as well as compliance with the assurances and subassurances. This evidence should consist of summarized findings of the Performance Measures (Discovery Data), and summarized results of all remediation actions taken when the state discovered any non-compliance related to any Performance Measures. Table 3 depicts what summarized evidence might look for one performance measure.

States are also expected to report on any quality improvement actions they have initiated, the reasons for conducting the quality improvement project, the nature of the intervention, and the empirical results of the improvement action (i.e., to what extent it worked, as measured by an improvement in the Performance Measure’s compliance rate). Currently, CMS requires states to submit information on waiver quality on an annual basis in a 372 report, a report that is waiver-specific and also includes waiver cost and utilization data.

In addition to the annual reporting, prior to waiver renewal CMS conducts an in-depth review of the waiver program and requires the state to submit evidence on all performance measures covering all discovery, remediation, and improvement activity reports for the first 3 years of the waiver (and for the first 18 months for a new waiver).7 After reviewing the state’s evidence package, CMS issues a Findings Report detailing whether the state met the assurances. For a state that could not demonstrate it met an assurance, the Findings Report will specify what it must do to come into compliance if CMS is to renew the waiver upon its expiration. A state found out of compliance is typically required to submit an action plan to CMS; once approved and the state begins implementation, CMS will monitor the state’s progress through state-submitted reports, teleconferences, and on-site visits.

States should also expect to be visited by CMS staff at least once during a waiver cycle. The purpose of these visits is for CMS to verify that the monitoring strategies that the state described in the approved waiver application are actually being implemented, and that monitoring reports are being generated in the frequency specified in the application and used by the state in operating the waiver. While on site, CMS may (1) interview state staff to better understand the processes and operations associated with the quality improvement strategy, (2) ”shadow” quality oversight staff as they conduct monitoring activities, (3) observe the state’s quality oversight meetings where performance measure data and remediation reports are reviewed and where quality improvement activities are planned and evaluated, and (4) visit providers to verify that the state is conducting provider reviews as described in the waiver application.

CMS may also visit a state if there are reports about program participants’ health and welfare being seriously jeopardized, or in the case of serious provider infractions. Additionally, through-out the waiver’s cycle, states should expect an ongoing dialogue with CMS about waiver quality; both state staff and CMS staff are expected to take responsibility for this interchange.

View full report


"primer10.pdf" (pdf, 2.08Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®