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How does a state comply with the admnistrative authority assurance?

As the accountable entity for an HCBS waiver, the state Medicaid Agency must show that it has final authority and oversight of all aspects of the program. States do this in several ways.

First, the state Medicaid Agency itself may operate an HCBS waiver. To meet this assurance, these states must show that the state Medicaid Agency is implementing the HCBS waiver in accordance with approved HCBS waiver design and that the agency conducts routine oversight of its operations.  

Second, the state Medicaid Agency may delegate the operation of an HCBS waiver to another division/unit within an umbrella state Medicaid Agency. In doing so, the state Medicaid Agency must establish formal methods for guiding and monitoring delegated activities. These may include memoranda of understanding, reporting requirements, or activities to regularly review performance. 

Third, an HCBS waiver may be operated by a division/unit/department outside of the state Medicaid agency. In these cases, there must be a formal, written agreement between the state Medicaid agency and the operating agency. These agreements usually specify:

  • The functions and activities that will be performed by the operating agency.

  • Oversight and policy setting responsibilities of each entity.

  • Authority and conditions related to sub-contracts between the operating agency and regional or sub-state entities.

  • Methods by which the state Medicaid Agency assumes full responsibility for waiver operations and performance. These may include reporting requirements, periodic audits, development of performance goals and strategies. 
Regardless of structure, a state Medicaid Agency must show that it has final authority and responsibility for the HCBS waiver. It must also demonstrate that it has the systems and procedures in place to monitor and improve performance.



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