Certified Provider A provider who meets criteria specified in the Department's regulations including the completion of a criminal history and background check.

Conflict of Interest A conflict of interest is when an individual or a company can financially or professionally benefit by influencing an individual's decision or choice.

CMS Centers for Medicare and Medicaid Services the agency in the Department of Health and Human Services that is responsible for federal administration of the Medicaid, Medicare and State Children's Health Insurance Program (SCHIP) programs. CMS was previously known as the Health Care Financing Administration (HCFA).

Criminal History/Background Investigation A process performed to determine if an individual has been convicted of a crime. This background check is conducted prior to employment and the requirements are specified in state law and regulations. In some cases a record may preclude the individual from providing direct supports or services to an individual with intellectual disabilities.

Eligibility

  1. Department Eligibility - diagnosis of intellectual disability as determined by an appropriate qualified professional
  2. Medicaid Eligibility determination by the state Medicaid agency that the individual meets the financial and any other specified criteria for Massachusetts Medicaid
  3. Waiver Eligibility - requires that the person be eligible for our services, eligible for Medicaid, and meet the specific requirements of the waiver program.

Enrollment An award of waiver funding to the individual and the implementation of the supports and services.

Financial Management Services This is the service that helps individuals to elect to self-direct services and for us to manage the individual's budget, and performs payroll functions including issuing paychecks, and withholding state and federal income taxes. The organization that does this for us is Public Partnerships Limited.

Free Choice of Provider The individual's right to obtain waiver services from any qualified and willing provider.

Freedom of Choice The right of an individual who is determined eligible for a waiver must state that they wish to receive community based services.

HCBS 1915 (c ) Waiver In 1981 the federal government authorized the Home and Community-Based Services (HCBS) Waiver which allowed states to use funds that would have been used to pay for nursing home or other institutional care, for a wide variety of home and community-based services for individuals who were living in institutions or at risk of entering institutions.

The HCBS waivers are agreements that we have with the federal government so eligible individuals can have more choices about how and where you receive services. We require eligible individuals to enroll in the Waivers so that the State can effectively manage its financial resources.

By offering Medicaid Waiver programs to eligible individuals the State receives reimbursement from the federal government for about 50% of the cost for services. In Massachusetts this money is returned to the general fund upon receipt.

ICF-ID Intermediate Care Facility for persons with Intellectual Disability a specialized type of institution (or in some states certain group homes) that is licensed and qualified under federal Medicaid regulations to serve individuals with developmental disabilities

Individual Budget The amount of money that we allocate to an individual to pay for needed supports and services. The allocation is based on assessed needs.

Interim/Provisional Plan of Care A state can enroll an individual in the HCBS waiver even if the service plan is not fully developed. The state can enroll the person with a provisional care plan and continue to work on finding additional services supports. As long as the person meets eligibility, the service(s) being delivered are allowable under the waiver program and the person's health and safety are assured, waiver-funded services can start even if the entire service plan is not fully developed

Individual Service Plan A Massachusetts Departmental document which specifies the supports and services, both generic and specialized, that an individual will receive based on assessed needs.

Level of Care To be eligible for the HCBS waiver, an individual must be eligible for care in an institution under Medicaid rules. This does not mean that the person has to live in an institution nor go to an institution, just be eligible for the type of care provided in an ICF-ID.

Licensed Provider A provider licensed by the State of Massachusetts to provide a professional service, examples include: doctors, nurse, speech pathologists, occupational therapists, physical therapists, or dentists.

Medicaid Medicaid is a publicly financed national health insurance program intended to provide basic health insurance for low income families, individuals who received cash welfare payments and individuals with disabilities. Medicaid is funded partially by the state and partially by the federal government.

Need A requirement for supports or services based on a professional, objective person-centered assessment that delineates areas what supports and/or services are necessary to assure health, safety and well being. Needs are addressed in the least intensive most integrated manner.

Participant Directed Service This option is sometime called Self Direction-this option gives you the most control over your supports and services and also the most responsibility. If you select this option you have choices on how much control you want to exercise.

  1. can decide to be the employer of the staff who provides their supports and services such as hiring, training and firing staff. In Massachusetts a Fiscal Management Service does the business processing including: enrollment, payroll functions, and budget management.
  1. is when an individual who is self-directing selects an agency to hire the individuals you selected to provide your supports and services. The agency agrees to help you train and manage the staff.
  1. means you can use a traditional/typical provider who will be responsible for hiring, training and managing the staff, supports and services and the Vendor Agency will be paid directly by us.

Individuals can use a combination of the above choices to meet their needs.

Plan of Care The document which specifies the waiver and other supports and services to be provided to an individual regardless of funding source. This also includes informal supports provided to meet the individual's needs to remain in the community. The plan must specify at a minimum the services, the type of provider to furnish the service, the frequency and duration. Federal financial participation (FFP) may only be claimed when authorized services in the service plan are provided.

Portability An individual can move from one area of the state to another and their individual budget and waiver eligibility can remain the same.

Qualified Provider A provider of a service or support that meets our specified criteria. A criminal history/ background check is required.

Reserved Waiver Capacity The state may reserve a portion of the participant capacity for specified purposes-such as community transition of institutionalized persons or for individuals who may experience a crisis.

Service Planning An initial discussion with the individual and their legal representative regarding supports and services needed, any preferences regarding location or providers and a discussion on funding sources for our services.

Slots The maximum number of individuals who can be enrolled in the waiver at any one point in time. The number of waiver slots is tied to amount of funding the state legislature has made available for waiver services. One "slot" usually equals the average amount of money the state expects to spend for an individual for a full year of services.

Target Group Refers to a group of qualified individuals who meet criteria specified by the state because they have similar needs, conditions or characteristics as defined by the state. A state must specify the target group(s) it plans to serve in the waiver.

Unduplicated Count The actual number of people served in the HCBS waiver that the state has specified to the federal CMS that it will not exceed in any given year of the waiver. The number includes each individual who was enrolled and received services as well as those who leave the program throughout the year. A state may limit to a number less than the total, the number of participants who will be served at any point in time during the waiver year, for example only enrolling a maximum number of individuals in any given month.

Waiver Mandate This term means that a state can determine that all individuals who qualify for the Medicaid waiver funding stream must utilize this source if they are to receive services. This is a fiscally responsible approach to maximizing federal and state revenues thus allowing the state to serve as many people as funding permits. It does not preclude the state from providing supports and services that are funded with only state general funds when the services do not meet the federal requirements or definitions.

Want A desire or preference not (necessarily) supported by an objective professional assessment.


This information is provided by the Department of Developmental Services.