CMS Revises Waiver Technical Guide

The Centers for Medicare and Medicaid Services (CMS) has posted a revision of the “Instructions, Technical Guide and Review Criteria” for the 1915(c) waiver application on the Waiver Management System (WMS) home page, along with updates to Resource Attachments to the guide.  The documents will be available under Links & Downloads at the link “1915(c) Waiver Application and Accompanying Materials.” 

The revised document incorporates several changes to align policy, guidance, and instructions with changes made to the 1915(c) waiver application in 2014, including:

  1. Changing “mental retardation” to “intellectual disability” and “Intermediate Care Facilities for the Mentally Retarded (ICF/MR)” to “Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)”
  2. Adding the option for a new waiver to be approved for five years if it serves people who are dually eligible for Medicare and Medicaid
  3. Adding several checkboxes to Attachment #1 of the 1915(c) waiver application, where states describe a transition plan when individuals may be adversely affected by an application
  4. Revising the quality improvement sections and Appendix H pursuant to guidance issued on March 14, 2014
  5. Adding the option for a state to indicate multiple target groups in Appendix B-1-a, consistent with 42 CFR §441.301(b)(6)
  6. Adding the HCBS Taxonomy, a standard categorization structure for Medicaid HCBS, to Appendix C-3
  7. Adding Appendix C-5 regarding compliance with home and community-based settings requirements
  8. Adding Appendix G-2-c for seclusion and removing seclusion from Appendix G-2-a, which now only applies to restraints

In addition, the revised document includes several policy clarifications:

Main Application

  1. Revised criteria for a retroactive amendment consistent with 42 CFR 441.304
  2. Clarification that states must ensure that any Medicaid administrative cost must be in accordance with a CMS-approved cost allocation plan, which is approved separately from a 1915(c) waiver
  3. Instructions for terminating a waiver
  4. The requirement to obtain public input in accordance with 42 CFR 441.304(f)
  5. Clarification of notice to tribal governments in accordance with Section 1902(a)(73) of the Social Security Act

Appendix A

  1. Specification that states must include the most recent execution date of the document utilized to outline the roles and responsibilities related to waiver operation when Appendix A-2-a indicates operation of the waiver by division or unit of the State Medicaid Agency other than the Medical Assistance Unit
  2. Clarification that the Medical Assistance Unit must oversee the operations of the entity in administering the waiver when Appendix A-2-a indicates operation of the waiver by division or unit of the State Medicaid Agency other than the Medical Assistance Unit
  3. Clarification that, when the waiver is not operated by the Medicaid agency, the State must specify the functions that are expressly delegated through a memorandum of understanding (MOU) or other written documents

Appendix C

  1. Clarification that extended state plan services in a waiver may only apply to adults age 21 and older because Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services mandate that Medicaid eligible children receive all medically necessary services coverable under §1905(a) of the Act
  2. Removal of instructions for Appendix C-2-c, regarding Keys Amendment facilities, which is no longer required because the necessary information regarding home and community-based settings will be provided in Appendix C-5
  3. Indication that case management must comport with conflict of interest requirements at 42 CFR 441.301(1)(vi)
  4. Clarification that the personal care service can be used to escort participants to community activities or to access other services in the community if the state explains how it is incidental to the personal care service and the transportation costs are included as a separate cost component in Appendix J
  5. Specification that employment related waiver services must be provided in accordance with a September 16, 2011, CMCS Informational Bulletin and revision of Core Service Definitions for employment related services according to this bulletin
  6. Clarification that a separate cost component in Appendix J is necessary if any of the following services includes assessments to determine the type of modification, technology, equipment, or supplies necessary: assistive technology, home accessibility modifications, vehicle modifications, and specialized medical equipment and supplies

Appendix D

  1. Revision of Appendix D-1-b, Service Plan Revision Safeguards, consistent with 42 CFR 441.301(c)(1)(vi)

Appendix G

  1. Clarification that use of restraints, restrictive interventions, and seclusion must comport with the home and community-based setting requirements at Section 42 CFR 441.301(c)(4)(iii) and (vi)(F), and person-centered service planning and plan requirements at 42 CFR 44.301(c)(1) and (c)(2)

FMI: The revised documents can be found at the Waiver Management System (WMS) home page (, by clicking the link in the left hand column called 1915(c) Waiver Application and Accompanying Materials. A summary of the changes, prepared by Truven for CMS, is available at