Good Faith Effort Request Form

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Centers for Medicare & Medicaid Services
Electronic Visit Verification
Good Faith Effort (GFE) Request Form – Personal Care Services

Instructions

Section 12006(a) of the 21st Century Cures Act (Cures Act) mandates that states implement electronic visit verification (EVV) for all Medicaid personal care services by January 1, 2020, or otherwise be subject to incremental federal medical assistance percentage (FMAP) reductions. The Cures Act includes a provision that allows states to delay implementation of EVV for up to one year if they have encountered unavoidable delays but can demonstrate they have made a good faith effort (GFE) to comply with the Cures Act. Please be advised that the Cures Act provision on GFE exemptions does not provide CMS with authority to delay the FMAP reductions for more than one year.

Please note the following information before completing this form:

  • Requests for GFE exemptions should be submitted by November 30, 2019 for PCS.
  • Only the State Medicaid Agency Director or his/her designee can submit this form.
  • This document is designed to be used electronically. It consists of the following sections. Section 2 and 3 must be completed in its entirety to be considered for GFE.
    • Section 1: Acronyms and Resources
    • Section 2: GFE Request Form
    • Section 3: State Medicaid Director Signature
  • To correctly fill out the document electronically, please follow the following tips:
    • For each response, click or tap on the box.
    • The open response questions have no character limits. Type as much or as little as you believe adequately answers each question. To enter text, click on the box, delete the placeholder text, and begin typing your response.
    • For "yes/no" and date–specific answers, click on the drop–down arrow to the right of the answer box and select the appropriate answer. Be sure the click outside the box after completing the question to ensure that the answer does not change.
    • Save the document often to avoid losing work!

If you have any questions, please email EVV@cms.hhs.gov or contact your CMS Regional Office.

Section 1. Acronyms and Resources

List of commonly used acronyms in this file

APD           Advance Planning Document

CFC          Community First Choice

EVV           Electronic Visit Verification GFE Good Faith Effort

HCBS        Home and Community–Based Service(s)

IAPD         Implementation Advance Planning Document

PAPD        Planning Advance Planning Document

PAS           Personal Assistance Service(s) PCS Personal Care Service(s)

SMA          State Medicaid Agency

SSA          Social Security Act

CMS EVV resources website link:
Click here to view detailed discussions of EVV models and section 12006 21st Century Cures Act requirements.

Section 2. Good Faith Exemption (GFE) Request Form

A. Basic State data

  • Date of Submission: Click or tap to enter a date. State: Click or tap here to enter State.
  • State Medicaid Agency (SMA) Requesting GFE: Click or tap here to enter SMA.
  • SMA Contact Information
    • Name: Click or tap here to enter name. Title: Click or tap here to enter title.
    • Email: Click or tap here to enter email.
    • Phone: Click or tap here to enter phone number.
    Indicate the Social Security Act (SSA) Authority and service type SMA requests GFE consideration:
    Authority PCS
    Section 1905(a)(24) state plan personal care benefit Choose an option.
    Section 1915(c) HCBS waivers Choose an option.
    Section 1915(i) HCBS state plan option Choose an option.
    Section 1915(j) self–directed PAS Choose an option.
    Section 1915(k) CFC state plan option Choose an option.
    Section 1115 demonstration projects Choose an option.

B. GFE Request Detail

  1. Has the state chosen an EVV model? Choose a response.
    1. If yes to above, please indicate the model chosen. Choose the EVV model type.
    2. If the model option chosen is "other", describe the model in detail here: Click or tap here to enter text.
    3. If no to above response, please indicate when the state anticipates selecting a model. Date will be in month/year format. Click or tap to enter a date.
  2. Has the state submitted an APD? Choose a response. If yes, please complete 2.a through 2.c.
    1. Type of APD submitted: Choose APD submission type.
    2. Date of APD submission: Click or tap to enter a date.
    3. Most recent APD approval date from CMS (if available): Click or tap to enter a date.
    4. If no to above response, explain why the state has not submitted an APD. Click or tap here to enter text.
  3. When is the state´s expected implementation date for PCS? Click or tap to enter a date in mm/yyyy format.
  4. In the table on the following page, please describe the state´s progress towards EVV implementation to date. If you do not see a relevant answer, please choose "other" and write the specific implementation status in the "detailed description of the implementation stage" column. Please add additional rows or attach additional documentation as needed. There are no character limits in each cell.
    This section includes seven parts.
    • Implementation Stage: States can choose from a CMS–defined list of EVV implementation stages. However, CMS does not expect that all states will define implementation stages in the same way. Therefore, if the state has a different implementation stage, please go to the "other" cell and describe in detail what the implementation stage is.
    • Detailed Description of the Implementation Stage: Describe the state´s current implementation process for this stage if it is in progress. If the state has completed this specific implementation stage, describe the activities that have been completed. States are free to attach any additional documents and reference these files in the description for further information.
    • Not Applicable: Check the box if the stage listed is not applicable to the state.
    • Is this stage delayed? Mark "Yes" or "No" depending on if the specific implementation stage is delayed. If "Yes", fill out step 6 in the pages below.
    • Date Completed: If implementation stage was completed, select the date in which the stage was complete.
    • If in process, anticipated date of completion: If the stage is in progress, mark the expected date of implementation.
    • Additional Information: There is an extra field included below the table to include more specific details and information about the state´s unique implementation process.
    Implementation Stage Detailed Description of the Implementation Stage Check if not applicable (N/A) Is this stage delayed? If yes, complete step 5. Date Completed If in the process, anticipated date of completion
    Planning – Environmental scanning Click or tap here to enter text. See above, in step 4, for more detailed instructions. ☐ Choose an option. Click or tap to enter a date. Click or tap to enter a date.
    Planning – Stakeholder meetings Click or tap here to enter text. See above, in step 4, for more detailed instructions. ☐ Choose an option. Click or tap to enter a date. Click or tap to enter a date.
    Planning – EVV model selection Click or tap here to enter text. See above, in step 4, for more detailed instructions. ☐ Choose an option. Click or tap to enter a date. Click or tap to enter a date.
    Modification of the existing contract to include EVV Click or tap here to enter text. See above, in step 4, for more detailed instructions. ☐ Choose an option. Click or tap to enter a date. Click or tap to enter a date.
    Preparing for RFP issuance Click or tap here to enter text. See above, in step 4, for more detailed instructions ☐ Choose an option. Click or tap to enter a date. Click or tap to enter a date.
    RFP issued and awaiting vendor bids Click or tap here to enter text. See above, in step 4, for more detailed instructions ☐ Choose an option. Click or tap to enter a date. Click or tap to enter a date.
    RFP closed and in the process of vendor selection Click or tap here to enter text. See above, in step 4, for more detailed instructions ☐ Choose an option. Click or tap to enter a date. Click or tap to enter a date.
    Vendor selected and developing work plans Click or tap here to enter text. See above, in step 4, for more detailed instructions ☐ Choose an option. Click or tap to enter a date. Click or tap to enter a date.
    Implementing work plans Click or tap here to enter text. See above, in step 4, for more detailed instructions ☐ Choose an option. Click or tap to enter a date. Click or tap to enter a date.
    Piloting the EVV system Click or tap here to enter text. See above, in step 4, for more detailed instructions ☐ Choose an option. Click or tap to enter a date. Click or tap to enter a date.
    Updating existing EVV system in the state Click or tap here to enter text. See above, in step 4, for more detailed instructions ☐ Choose an option. Click or tap to enter a date. Click or tap to enter a date.
    Other implementation stages not described above (Please detail the state's current implementation stage in the next column.) Click or tap here to enter text. See above, in step 4, for more detailed instructions ☐ Choose an option. Click or tap to enter a date. Click or tap to enter a date.
    Other implementation stages not described above (Please detail the state's current implementation stage in the next column.) Click or tap here to enter text. See above, in step 4, for more detailed instructions ☐ Choose an option. Click or tap to enter a date. Click or tap to enter a date.
    Other implementation stages not described above (Please detail the state's current implementation stage in the next column.) Click or tap here to enter text. See above, in step 4, for more detailed instructions ☐ Choose an option. Click or tap to enter a date. Click or tap to enter a date.
    Other implementation stages not described above (Please detail the state's current implementation stage in the next column.) Click or tap here to enter text. See above, in step 4, for more detailed instructions ☐ Choose an option. Click or tap to enter a date. Click or tap to enter a date.
  5. In the table on the following page, choose the type of unavoidable delays the state has encountered related to EVV implementation. For each choice, describe in detail what the delays are, why those delays have occurred, and what the state´s plans are for addressing the delays. The list provided in the table includes examples of potential delays and will not encompass each unique circumstance of each state. If you do not see a relevant answer, please choose "other" and write the specific delay situation in the "detailed description of the delay" column. Please add additional rows or attach additional documentation as needed. There are no character limits in each cell.

    This section includes four parts:
    1. Detailed Description of the Delay: Detail the state´s circumstances for the delay. Describe and what specific events have occurred to cause this delay.
    2. Why Delays Occurred: Detail why the state believes the cause of the delay happened.
    3. State´s Mitigation Plan: Detail the state´s plan for addressing the delay going forward.
    4. Estimated Date of Completion: Enter the estimated date that the state believes the task can and will be completed.
    Type of Unavoidable Delay Detailed Description of the Delay Why Delays Occurred State's Mitigation Plan Estimated Date of Completion
    Procurement issues Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap to enter a date.
    Budget and/or legislation appropriation issues / Funding issues Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap to enter a date.
    Stakeholder engagement issues Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap to enter a date.
    System interoperability issue or IT issue Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap to enter a date.
    Other issues not discussed above (Please detail your delay in the next column) Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap to enter a date.
    Other issues not discussed above (Please detail your delay in the next column) Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap to enter a date.
    Other issues not discussed above (Please detail your delay in the next column) Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap to enter a date.
    Other issues not discussed above (Please detail your delay in the next column) Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap here to enter text. See above, in step 5, for more detailed instructions. Click or tap to enter a date.

Section 3. Medicaid Director Signature

This document is only accepted if the State Medicaid Director signs this form. States can print this file, sign, date the signature, and submit the signature page separately in a PDF file format or add a digital signature. To add a digital signature, right click on the signature line below and choose "sign" option and follow the prompts.

I, Click or tap here to enter Medicaid Director name, attest that the information provided in this form is accurate and reflective of the current activities regarding EVV of my state.


State Medicaid Director Name: Click or tap here to enter Medicaid Director name


State Medicaid Director Title: Click or tap here to enter Medicaid Director title


State Medicaid Director Signature



X _________________________________________
      State Medicaid Director Signature



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