Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Continuous Quality Improvement: Design


“Design” refers to a state’s plan for how it will monitor a waiver program and make improvements when systemic problems are detected. States must describe this plan in the waiver application. In 2005, CMS issued a new waiver application format, which elicits specific information about a state’s design of its quality monitoring and improvement strategy.4 In the waiver application, a state must describe how it will “discover” when the assurances have not been met, its plans for monitoring whether the individual problems it uncovers are “remediated” or fixed, and how it will engage in system “improvement” activities when it discovers that there are systemic problems responsible for an accumulation of individual problems. A state’s CQI design must be organized around the Federal assurances, described in Table 1.

Each assurance embodies more than one programmatic expectation. In the waiver application, CMS has articulated many subassurances--in order to operationalize the six assurances in concrete terms in accordance with CMS policy. CMS’s articulation of subassurances seeks to ensure that states monitor the aspects of the program CMS deems fundamental. A few examples of subassurances are presented in Table 2. A full listing of the subassurances may be found in the most current version of the §1915(c) waiver application. (See the Resources section of this Appendix for a link to the application.)

TABLE 1. Section 1915(c) Federal Assurances
Level of Care Persons enrolled in the waiver have needs consistent with an institutional level of care.
Service Plan Participants have a service plan that is appropriate to their needs and preferences, and receive the services/supports specified in the service plan.
Provider Qualifications Waiver providers are qualified to deliver services/supports.
Health and Welfare Participants’ health and welfare are safeguarded.
Financial Accountability Claims for waiver services are paid according to state payment methodologies specified in the approved waiver.
Administrative Authority The state Medicaid agency is actively involved in the oversight of the waiver, and is ultimately responsible for all facets of the waiver program.

TABLE 2. Examples of Subassurances
(Version 3.5 of the §1915(c) Waiver Application)
Level of Care The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver
Service Plan Service plans are updated/revised at least annually or when warranted by changes in the waiver participant’s needs
Service Plan Services are delivered in accordance with the service plan, including in the type, scope, amount, and frequency specified in the service plan.
Service Plan Participants are afforded choice: between waiver services and institutional care; and between/among waiver services and providers.
Provider Qualifications The state verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other state standards prior to their furnishing waiver services.

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