DDA-Operated Medicaid Waiver Programs
Coordinators of Community Services (CCS) Waiver Application Packet Review Checklist
OVERVIEW
This checklist is used by Coordinators of Community Services (CCS) to ensure review and completion of
key steps associated with the DDA Waiver Application Process. Please reach out to the DDA Regional for
technical assistance needs.
Important Note: An applicant must have an Assessed Need for Residential to be apply and be enrolled in
the Community Pathways Waiver
Please verify that all of the information in LTSS Maryland is correct.
ENROLLMENT CHECKLIST
Medicaid (MA) Waiver Application
(Long Form , Short Form)
The CCS should ensure that:
The Medicaid Waiver Application is for the correct applicant
The Applicant’s name, date of birth, address, social security number, and Medicaid number (as
applicable) match LTSS Maryland information as applicable
The MA Waiver Application includes the following information on the upper right hand corner:
DDA Waiver Program Type ( i.e., FSW, CSW, or CPW)
The CCS’ initials
The date the document was signed
The MA Waiver Application Program Type matches with the Wave Program
The MA Waiver Application is signed by the applicant and their authorized representative (if
applicable)
If authorized representative signs, upload the proof of Power of Attorney with the application
The applicant signed and dated the document
The MA Waiver application is uploaded within 1-3 business days of the signature date
Long Form - DHR/FIA 9709 , Short Form - DHR/FIA 9709S
Person-Centered Plan (PCP)
The CCS should ensure that:
The PCP is an “Initial” plan
The PCP Program Type matches with the MA Waiver Application Program Type and the Wave
Program Type ( i.e., FSW, CSW, or CPW)
The applicant’s story and immediate goals are reflected throughout the PCP including what’s working
and what’s not working
Exploration and documentation of natural and other community-based supports beyond DDA are
reflected throughout the PCP
The applicant’s assessed unmet need for services and supports are reflected throughout the PCP
If Residential Services are requested, the PCP must reflect an assessed need for residential services as
referenced in the Waiver
PCP is submitted within 10 business days of wave placement
▶ Issue Date: 4/11/2024
Developmental Disabilities Administration Page 1 Find Out More: 844-253-8694 | dda.health.maryland.gov
DDA-Operated Medicaid Waiver Programs
Coordinators of Community Services (CCS) Waiver Application Packet Review Checklist
Level of Care - LOC
The CCS should ensure that:
The LOC Form is for the correct applicant
The Applicant has a “Developmental Disability” (DD) eligibility determination in LTSS Maryland >
Programs > DDA Eligibility > Eligibility Determination Form
If the applicant is not DD Eligible, then reach out to the Regional Office
The LOC is an “Initial” LOC
The uploaded “Initial LOC” document matches the eligibility determination date in LTSS Maryland
The form is signed by the CCS
Freedom of Choice Form - FOC
The CCS should ensure that:
The FOC form is for the correct applicant
The person’s choice to receive services from the waiver and following have been selected:
Choose to receive home and community-based services under the Maryland Medical
Assistance program/DDA Waiver Programs
A Service Delivery Model
Service Delivery Model must be the same as in the Level of Care form
The FOC form is signed by:
The applicant or their representative (if applicable)
The CCS and date noted
EDD Release Form
The CCS should ensure that:
The EDD Release form is for the correct applicant
The EDD Release Form is signed by:
The person and their representative (as applicable) and date noted
Waiver Meeting Minutes
The CCS should ensure that:
There is discussion about:
The applicant’s story and immediate goals
The applicant’s current services and supports ( e.g., natural, local, community, Community
First Choice, Housing Voucher, etc.)
What’s working and what’s not working
Unmet needs and any services ending in the near future
Referrals to other programs and status
The Waiver meeting attendance is taken
▶ Issue Date: 4/11/2024
Developmental Disabilities Administration Page 2 Find Out More: 844-253-8694 | dda.health.maryland.gov
