Fillable Louisiana Medicaid Freedom of Choice List Template

Fillable Louisiana Medicaid Freedom of Choice List Template

The Louisiana Medicaid Freedom of Choice List form serves as a significant tool for providers seeking to offer waiver services under Medicaid. It ensures that current details such as provider names, addresses, and contact information are accurately listed and allows for the selection of services they are qualified to provide, ranging from psychological support to medical equipment supplies. If you're a provider aiming to either join or update your information on the Medicaid Freedom of Choice List, completing and submitting this form is an essential step.

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Modify Louisiana Medicaid Freedom of Choice List

In the state of Louisiana, Medicaid beneficiaries have the advantage of selecting from an array of waiver services providers, a choice that underscores the empowerment of those in need of specialized healthcare and support services. Central to this process is the Louisiana Medicaid Freedom of Choice (FOC) List form, designed meticulously to cater to this need. The form acts as a request submission tool for providers seeking to either enter or update their information in the Medicaid database, ensuring that current and prospective Medicaid recipients are presented with up-to-date options for their care needs. Requiring providers to supply both current and, if applicable, previous information, the form covers a wide range of service fields—from Children’s Choice Waiver to specialized care services like Skilled Nursing, Occupational Therapy, and Speech Therapy, among others. It is not only a document but a dynamic interface between the state’s healthcare system and providers, thereby facilitating a spectrum of choices for beneficiaries across regions. Additionally, the meticulous nature of the form, which mandates the inclusion of a provider’s contact information, areas of service, and licensing details, underscores the Louisiana Department of Health's commitment to ensuring the quality and accessibility of healthcare providers. With a signature and title from the provider, coupled with the requirement for prompt updating of any changes within a ten-day frame, the form stands as a testament to ongoing diligence and responsiveness to the needs of Medicaid beneficiaries in Louisiana.

Form Preview Example

MEDICAID FREEDOM OF CHOICE LIST FOR WAIVER

SERVICES: PROVIDER REQUEST

Please Print/Type ALL Information Requested:

 

Current Information

 

Previous Information

 

 

 

 

Provider Name:

 

Former Name:

 

 

 

 

Provider Address (Include City, State, Zip):

Former Address:

 

 

 

Provider Contact Name:

Former Provider Contact Name:

 

 

ProviderPhone- FaxNumber(s)(Includeareacode):

PreviousProviderPhone- FaxNumber(s)(Includeareacode):

Phone:

Fax:

Phone:

Fax:

 

 

Provider Toll-Free Phone Number:

Former Provider Toll Free Phone Number:

 

 

 

Provider E-Mail

 

Former Provider E-Mail

 

 

 

 

Please place/update/remove the above-named agency on/from the Freedom of Choice list for the provider type(s) checked below.

 

03

Children’s Choice (Children’s Choice Waiver)

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

 

06

Professional Services [NOW]

 

 

 

 

 

 

 

 

 

Checkallapplicableservices:

Psychologist

SocialWorker

Nutritional/Dietary

 

Region(s):

 

 

11

Shared Living (ROW)

 

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

 

13

Pre-Vocational

 

 

 

 

 

Region(s):

 

 

14

Day Habilitation

 

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

 

15

Environmental Modifications

 

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

16

Personal Emergency Response System (PERS)

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

17

Medical Equipment and Supplies (Assistive Devices)

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

 

31

Psychologist (ROW)

 

 

 

 

 

Region(s):

 

 

33

Monitored In Home Caregiving (NOW)

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

35

Monitored In Home Caregiving (ROW)

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

35

Physical Therapist

CC

ROW

Both CC and ROW

 

Region(s):

 

 

37

Occupational Therapist

CC

ROW

Both CC and ROW

 

:

 

 

 

 

 

Region(s)

 

 

39

Speech Therapist

CC

ROW

Both CC and ROW

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

 

41

Registered Dietician (ROW)

 

 

 

 

 

Region(s):

 

 

44

Skilled Nursing (NOW)

 

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

 

44 (4W)

Skilled Nursing (ROW)

 

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

 

73

Social Worker (ROW)

 

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

82

Personal CareAttendant(PCA):

CC/NOW/SW

 

ROW

 

Region(s):

 

 

 

 

 

 

 

 

 

 

82 (4W)

If ROW selected above: Check

Community LivingSupports

 

 

Region(s):

 

 

 

Companion Care Support

 

 

 

 

 

 

one:

 

 

 

 

 

 

Both CLS and CCS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

83

Center-Based Respite

 

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

 

84

Substitute Family Care:

NOW

 

 

ROW

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

85

ROW Adult Day Health Care (ADHC)

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

89

Supervised Independent Living (SIL) – (NOW)

 

 

 

 

Region(s):

 

 

98

Supported Employment

 

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

Provider’s Signature and Title:

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

ItistheProvider’s Responsibility tonotifytheLouisianaDepartmentofHealth(LDH),WaiverSupportsandServices,regardinganychangesinthe above noted information within ten (10) days of any changes. To keep from being removed from the FOC list, a provider’s license and enrollment must be kept current. This notice will NOT notify DXC Provider Enrollment or Licensing regarding these changes.

The following must be included with all submissions:

Completed 1.) FOC Form, 2.) A copy of your current license, and 3. A copy of your current Medicaid Provider Enrollment Letter(s).

Mail or Fax to:

OCDD/Waiver Supports & Services

628North 4th Street, 2nd Floor Baton Rouge, LA 70802 Fax: (225) 342-8823

Issued July 30, 2020

OCDD-PF-20-005

Replaces all prior issuances

 

Document Information

Fact Name Description
Purpose of the Form This form is used to request that a provider be placed on, updated, or removed from the Louisiana Medicaid Freedom of Choice List for waiver services.
Information Required Providers must supply current and previous information such as names, addresses, contact details, and service types they are requesting to be listed for.
Service Types The form lists various provider types and services, including psychological services, nutritional/dietary services, skilled nursing, social work, and more, indicating a diverse range of services under Medicaid waivers.
Responsibility for Updates Providers are responsible for notifying the Louisiana Department of Health about any changes in the information provided within ten days to avoid being removed from the list.
Submission Requirements Providers must include the completed form, a copy of their current license, and a copy of their current Medicaid Provider Enrollment Letter(s) when submitting updates or requests.
Contact Information for Submission The completed form and required documents should be mailed or faxed to the Office for Citizens with Developmental Disabilities/Waiver Supports & Services at the provided address and fax number.
Governing Law The form is issued under the purview of the Louisiana Department of Health, specifically the Office for Citizens with Developmental Disabilities, and is subject to state healthcare laws and regulations.

Steps to Writing Louisiana Medicaid Freedom of Choice List

After deciding to become a provider for waiver services under the Louisiana Medicaid program, it's vital to complete the Medicaid Freedom of Choice List for Waiver Services: Provider Request form accurately. This form is crucial for providers who wish to offer services to Medicaid beneficiaries within specific waiver programs. It's necessary for updating, adding, or removing provider details in the Medicaid system. Ensuring that all details are correctly filled out and current documentation is attached confirms your eligibility and maintains your standing as a Medicaid service provider. Here's how to navigate the form completion process:

  1. At the top of the form, where it requests "Current Information," provide the actual name of the provider or agency, current provider address including city, state, and zip code, and the current provider contact name.
  2. In the fields marked "Provider Phone - Fax Number(s) (Include area code)," enter the current phone number and fax number of the provider, ensuring area codes are included. If the provider has a toll-free number, that should be filled in the “Provider Toll-Free Phone Number” section.
  3. If there has been a change in provider details, fill in the "Previous Information" section with the former name, address, and contact details, including the previous phone and fax numbers, and toll-free number if applicable.
  4. In the section for the provider's email, enter the current email address in the "Provider E-Mail" field. If it has changed, supply the former email in the corresponding field.
  5. Under the section asking to place, update, or remove the agency from the Freedom of Choice list, check the appropriate action and then proceed to select the provider type(s) by checking the corresponding boxes.
  6. Mark all applicable services the provider intends to offer from the listed options. Ensure to specify the region(s) for each selected service by ticking the appropriate boxes.
  7. If applicable, indicate the preference between Community Choice (CC), Residential Options Waiver (ROW), or both for specific services by checking the relevant boxes.
  8. At the bottom of the form, the provider must sign and date, confirming the request. The provider's title should also be clearly stated next to their signature.
  9. Ensure to attach a copy of the current license and a copy of the current Medicaid Provider Enrollment Letter(s) with the form submission.
  10. Mail or fax the complete package to the specified address: OCDD/Waiver Supports & Services, 628 North 4th Street, 2nd Floor, Baton Rouge, LA 70802 or fax to (225) 342-8823.

Remember, it's the provider's responsibility to notify the Louisiana Department of Health (LDH), Waiver Supports, and Services, regarding any changes in the provided information within ten (10) days of any such changes. This proactive measure ensures continuous compliance and maintains the integrity of the services offered to Medicaid beneficiaries.

Frequently Asked Questions

What is the Medicaid Freedom of Choice List for Waiver Services?

The Medicaid Freedom of Choice (FOC) List for Waiver Services is a directory of approved providers who have elected to offer services under specific Medicaid waiver programs in Louisiana. These programs are designed to offer various services that support individuals with disabilities and certain health conditions to live more independently in their communities. Providers on this list have met all of the necessary requirements and have agreed to comply with the standards and guidelines set forth by the Medicaid program.

How do I add my agency to the Freedom of Choice list?

To add your agency to the Freedom of Choice list, you must complete the FOC form, including all requested current and, if applicable, previous information such as provider name, address, contact details, and the types of services you are requesting to provide. Additionally, you must include a copy of your current license and a copy of your current Medicaid Provider Enrollment Letter(s). The completed form and accompanying documents should then be mailed or faxed to the address provided on the form.

Can I update my agency's information once it is on the Freedom of Choice list?

Yes, you can update your agency's information on the Freedom of Choice list. It is your responsibility to notify the Louisiana Department of Health (LDH), Waive Supports and Services, regarding any changes in the information previously submitted. Changes must be reported within ten (10) days. The update process requires submitting the updated information using the same form used for initial registration, indicating what changes have occurred.

What types of services can be provided by agencies on the Freedom of Choice list?

Agencies on the Freedom of Choice list can provide a range of services depending on the waiver programs they are approved for. These services can include, but are not limited to, psychological services, social work, nutritional/dietary advice, shared living, day habilitation, personal emergency response systems, medical equipment and supplies, various therapies (such as physical, occupational, and speech therapies), skilled nursing, personal care attendants, and more. Each service is tied to specific waiver programs such as Children’s Choice, NOW, ROW, and others.

What is required to maintain my agency's listing on the Freedom of Choice list?

To maintain your agency's listing on the Freedom of Choice list, you must ensure that your license and Medicaid enrollment are kept up to date. Any changes to your agency’s information must be reported promptly, within ten days of the change. Failing to maintain current documentation or to notify the LDH of changes may result in your agency being removed from the list.

Where do I mail or fax the completed Medicaid Freedom of Choice List form and accompanying documents?

The completed Medicaid Freedom of Choice List form along with copies of your current license and Medicaid Provider Enrollment Letter(s) should be mailed or faxed to OCDD/Waiver Supports & Services, 628 North 4th Street, 2nd Floor, Baton Rouge, LA 70802. The fax number is (225) 342-8823.

What happens if I do not notify the Louisiana Department of Health about changes in my agency’s information?

If you do not notify the Louisiana Department of Health about changes in your agency’s information within the required ten (10) days, your agency risks being removed from the Freedom of Choice list. This could impact your ability to provide services under Medicaid waiver programs and potentially result in a loss of clients who require those services.

What is the significance of the provider types and regions checked on the form?

On the FOC form, providers are asked to check the types of services they wish to provide and the regions in which they will provide them. This information helps match providers with Medicaid recipients in need of specific services within those regions. It ensures that a wide range of services is available to Medicaid waiver participants throughout the state, facilitating access to necessary care and support.

How often should the Freedom of Choice List form be updated?

The Freedom of Choice List form should be updated any time there is a change in your agency's information, including a change of address, contact details, services provided, or if you wish to add or remove services from your listing. Prompt updates ensure the accuracy of the list and aid in connecting individuals in need with appropriate providers.

Where can I find more information about the Medicaid waiver programs and services offered in Louisiana?

For more detailed information about the Medicaid waiver programs and the services offered in Louisiana, you should visit the Louisiana Department of Health's website or contact the Office for Citizens with Developmental Disabilities (OCDD). The website provides comprehensive information about each waiver program, including eligibility criteria, available services, and how to apply for services. Additionally, you can reach out directly to the LDH or OCDD for more personalized assistance.

Common mistakes

When filling out the Louisiana Medicaid Freedom of Choice List form for waiver services, individuals commonly make several mistakes, which can delay or affect the submission process. Understanding these common errors can help ensure the form is completed accurately.

  1. Not printing or typing all the information requested on the form. The form specifically asks for information to be printed or typed to ensure legibility.
  2. Forgetting to update both the current and previous information sections. It's vital to include any changes in provider details, including addresses and contact information.
  3. Omitting area codes for phone and fax numbers. Including area codes is necessary for completeness and for verification processes.
  4. Overlooking the request to list a toll-free phone number, if available. Having a toll-free number listed can make it easier for patients to reach out.
  5. Leaving the email address section blank or not updating it. Email communication is a key component for timely updates and inquiries.
  6. Failing to check off the appropriate provider type(s) and regions served. This ensures that providers are correctly listed for the services and areas they cover.
  7. Not signing the form or including a title. A signature and title verify the authority of the individual completing the form and their relationship to the provider.
  8. Ignoring the responsibility to notify the Louisiana Department of Health (LDH) within ten days of any changes. Timely updates are crucial for maintaining accurate listings.
  9. Neglecting to include all required documents with the submission, namely the completed Freedom of Choice (FOC) Form, a copy of the current license, and a current Medicaid Provider Enrollment Letter(s).

By paying close attention to these areas, providers can ensure their submission process for the Louisiana Medicaid Freedom of Choice List form is smooth and error-free.

Documents used along the form

When a Louisiana Medicaid provider intends to offer waiver services, they must interact with a number of documents in addition to completing the Louisiana Medicaid Freedom of Choice List form. These forms and documents are essential for ensuring that the provider is compliant with state regulations and is properly enrolled to offer Medicaid services.

  • Medicaid Provider Enrollment Application: This is a required document for any provider seeking to become authorized to offer services to Medicaid recipients. It gathers detailed information about the provider's qualifications, background, and the services they intend to offer.
  • Copy of Current License: Providers must submit a copy of their current professional license. This document verifies that the provider is legally recognized in their field of practice by the relevant Louisiana state board or authority.
  • Medicaid Provider Agreement: This document outlines the terms and conditions under which the provider will render services to Medicaid participants. It includes compliance with state laws, billing procedures, and other operational guidelines.
  • Criminal Background Check Authorization: A document that authorizes the conduct of a criminal background check on the provider. This is critical for ensuring the safety and well-being of Medicaid recipients.
  • W-9 Form: This IRS form is needed to provide taxpayer identification number and certification. It is essential for the Medicaid program to process payments to the provider.
  • Proof of Malpractice Insurance: Providers must furnish evidence of their current malpractice insurance coverage. This serves as protection for both the provider and clients in case of a malpractice claim.
  • Privacy Practices Acknowledgment: A document where the provider acknowledges their understanding and compliance with HIPAA (Health Insurance Portability and Accountability Act) privacy practices, ensuring the protection of confidential health information.

Each document plays a crucial role in the enrollment and operation as a Medicaid provider in Louisiana. The process involves thorough verification and compliance to maintain high standards of service for Medicaid recipients. By carefully completing and submitting these documents, providers contribute to a robust and accessible healthcare system for all Medicaid participants in the state.

Similar forms

The Louisiana Medicaid Freedom of Choice List form is similar to other forms used within the healthcare industry to ensure that a patient’s care or service preferences are recorded. These could include forms within Medicare, private health insurance plans, and other state Medicaid programs. Each of these forms, while varying in specifics, share the common goal of documenting the services a provider is authorized to deliver, and any changes to those services or the provider's contact information.

Medicare Enrollment Application (CMS-855I) - This is a close counterpart; it is used by individual practitioners and groups to apply for enrollment in the Medicare program. Both forms require detailed provider information, including changes in address or contact information. However, while the Louisiana Medicaid Freedom of Choice List specifically relates to waiver services and the provider's chosen service regions, the CMS-855I is broader, encompassing a wide range of medical services without focusing on specific regions or the waiver aspect.

Provider Change of Information Form in Private Insurance - Private insurance companies often use a generic form for providers to update their information or services. Similar to the Louisiana Medicaid Freedom of Choice List form, these documents serve to update the insurer about changes in the provider’s contact details, services offered, or any other critical information that affects patient choice or billing. The specific details and layout of these forms can vary by company but the fundamental purpose aligns closely with maintaining up-to-date records to facilitate patient freedom of choice in provider selection.

State Medicaid Provider Enrollment Forms - Other states besides Louisiana have their versions of Medicaid Provider Enrollment or Update forms, which are remarkably similar in function and intent to the Louisiana Medicaid Freedom of Choice List form. While each state has its Medicaid program nuances, these forms universally collect provider information, service offerings, and any pertinent changes to ensure Medicaid recipients have access to up-to-date, accurate information about their healthcare providers. These forms play a crucial role in coordinating healthcare services and maintaining the integrity and efficiency of Medicaid programs.

Dos and Don'ts

When filling out the Louisiana Medicaid Freedom of Choice (FOC) List form for waiver services, there are some dos and don'ts that can help ensure your submission is processed smoothly and effectively. Here are three things you should do, followed by three things you shouldn't.

Do:

  1. Print or Type Clearly: Make sure all information requested on the form is provided in a legible manner. This includes current and previous information about the provider, such as names, addresses, phone numbers, fax numbers, and email addresses. Clarity helps in avoiding misinterpretations and ensures accurate processing.

  2. Include All Required Documentation: Along with the completed FOC Form, ensure you attach a copy of the provider's current license and a copy of the current Medicaid Provider Enrollment Letter(s). These documents are crucial for the validation of your request.

  3. Notify of Any Changes Within Ten Days: It is the provider’s responsibility to inform the Louisiana Department of Health (LDH), Waiver Supports, and Services about any changes to the information provided on the form within ten (10) days of any changes. Prompt updates help maintain the accuracy of the Freedom of Choice list.

Don't:

  1. Leave Sections Blank: If a section of the form does not apply, rather than leaving it blank, it's advisable to fill it with “N/A” or “Not Applicable.” This indicates that you have reviewed the section and determined it does not apply to your situation.

  2. Forget to Sign and Date: The provider’s signature and title, along with the date at the bottom of the form, are mandatory. An unsigned or undated form may be considered incomplete and can delay the process.

  3. Assume Submission Equals Notification to All Departments: Completing and submitting this form will not notify DXC Provider Enrollment or Licensing about the changes. Make sure to separately inform relevant departments as required.

Adhering to these guidelines will not only streamline the application process but also ensure compliance with the Louisiana Department of Health's requirements, facilitating a smoother and more efficient updating of the Freedom of Choice list for waiver services providers.

Misconceptions

When understanding the Louisiana Medicaid Freedom of Choice List form, there are common misconceptions that may lead to confusion. It’s important to clarify these misconceptions to ensure that providers and patients alike have a clear understanding of the procedures and implications of this document. Below are five common misconceptions about the Louisiana Medicaid Freedom of Choice List form along with explanations for each:

  • Completing the form automatically updates all provider information with Medicaid: It's a common misunderstanding that once the Freedom of Choice (FOC) form is completed and submitted, all provider information updates are automatically reflected across all Medicaid systems. However, this form specifically updates the FOC list only. Providers are responsible for notifying the Louisiana Department of Health (LDH) and any relevant Medicaid enrollment or licensing bodies separately within ten days of any changes.
  • The form only needs to be submitted for new services: Some believe that the FOC form is only required when a provider begins offering new services. While it's true that the form must be used to update the list of services provided, it's also necessary for updating any provider information such as addresses, phone numbers, and email addresses. It's critical for maintaining current and accurate information on the FOC list.
  • Providers are automatically removed from the list if they do not update their form: There is a misconception that providers are automatically removed from the Freedom of Choice list if they fail to update their form regularly. The reality is that providers must keep their license and enrollment current to avoid being removed from the list. It's the responsibility of the provider to ensure that all of their credentials are up to date.
  • The form is only applicable to certain Medicaid waivers: While the form lists specific waiver services, such as the Children’s Choice Waiver or the Residential Options Waiver (ROW), some might wrongly assume that it is only relevant to providers of those services. In truth, the form is designed to be used by a wide range of service providers who offer various types of Medicaid waiver services, ensuring a comprehensive listing on the FOC list.
  • Submission of the FOC form is the sole responsibility of the Medicaid service provider: Although it is primarily the provider's responsibility to complete and submit the FOC form, it's also critical for the success of Medicaid participants to have access to up-to-date and comprehensive provider information. Therefore, both parties benefit from accurate and current listings. Providers, participants, and the LDH all play crucial roles in maintaining the integrity and utility of the Freedom of Choice list.

In addressing these misconceptions, it becomes clear that the Louisiana Medicaid Freedom of Choice List form serves as an essential tool in the management of Medicaid waiver services, facilitating accurate provider information and ensuring that Medicaid participants have the freedom to choose their providers wisely and informedly.

Key takeaways

When dealing with the Louisiana Medicaid Freedom of Choice List form, it's important to grasp its purpose and requirements to ensure that providers can accurately and efficiently request to offer waiver services. Here are several key takeaways:

  • All requested information must be printed or typed clearly to ensure that the form is readable and that all entries are accurately recorded. This clarity helps in avoiding delays in processing the form due to illegible handwriting or typographical errors.
  • Providers must indicate any changes to their current information as compared to their previous information. This includes updates to the provider's name, address, contact name, phone and fax numbers, toll-free number, and email address. Such comprehensive information is crucial for maintaining up-to-date records and ensuring effective communication.
  • The form requires selection of the provider type(s) for which the agency is requesting to be placed on or removed from the Freedom of Choice (FOC) list. Providers need to accurately identify the service(s) they intend to render, showcasing the form's role in detailing the provider's service offerings.
  • Region-specific service offerings indicate that providers must specify the regions in which they will provide each service. This geographical designation ensures that services are appropriately distributed and accessible to beneficiaries across different areas.
  • Providers are responsible for notifying the Louisiana Department of Health, Waiver Supports and Services, about any changes to the provided information within ten days. This highlights the importance of maintaining current and accurate provider information, emphasizing the provider's role in ensuring data reliability.
  • To avoid being removed from the FOC list, a provider must ensure that their license and Medicaid provider enrollment are kept current. This requirement underscores the importance of compliance with state regulations to remain eligible to offer waiver services.
  • The submission process requires inclusion of the completed FOC form, a copy of the current license, and a copy of the current Medicaid Provider Enrollment Letter(s). This documentation proves the provider's qualifications and authorization to offer Medicaid waiver services, ensuring that only legitimate providers are listed.
  • Completed forms and accompanying documents should be mailed or faxed to the specified address and fax number provided on the form. This directive offers clear guidance on how to submit the necessary paperwork to the relevant department within the state's health administrative infrastructure.

Understanding these details helps providers in filling out the Louisiana Medicaid Freedom of Choice List form correctly and comprehensively, facilitating smoother transactions with the Louisiana Department of Health, and contributing to the betterment of waiver services offered to Medicaid recipients.

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