Application Checklist

Section 18, 20, 21 and 29: Prospective Waiver Providers

DHHS may authorize agencies to provide services after an application, along with supporting documentation, has been submitted to a Designated Representative for review and approval. Agencies must meet DHHS expectations in the areas of organization and operation, operation of individual programs or services, personnel administration, environment and safety, and quality management.

Application Form and Supporting Documentation should be submitted via email to

Application Form

  • This form should be signed/dated and identify the primary contact person.
  • Please ensure that you include the services that you are proposing to deliver by their titles; these can be found in the Covered Services portion of Ch. II Section 18, Ch. II Section 20, Ch. II Section 21, and/or Ch. II Section 29 of the MaineCare Benefits Manual.

Supporting Documentation

  1. Organization and Operation
    1. Evidence of source(s) of authority to provide services: articles of incorporation, corporate charter, or similar documents.
    2. Records of the contact information for officers, directors, charters, partnership agreements, constitutions, articles of association and/or by-laws, as applicable.
    3. Written job descriptions for all positions within the agency.
    4. Evidence to demonstrate the appropriate qualifications of persons engaged or planning to engage in the provision of services, as well as supervisors of those that provide services.
    5. Evidence of management competency and experience in the health or human service setting, as well as good standing of licensure or certification.
    6. Copies of contracts or service agreements, when the provider manages or plans to manage services delivered by others.
    7. Organization Chart, outlining the business structure, identifying management, staff and other individuals compensated by the provider for providing services and illustrating supervisory responsibilities, including credentials as required.
    8. Financial Management- the provider shall make available to DHHS upon request, a federal income tax return for the year in question, a statement of finances including income statement, balance sheet, cash flow statement, operations and program budget, and profit projection.
  2. Operation of Individual Programs or Services

    Policies governing essential elements of service provision, including but not limited to:

    1. Ensuring compliance with the Regulations Governing Behavioral Support, Modification and Management for People with Intellectual Disabilities or Autism in Maine (14-197 CMR ch. 5),

    Ensuring compliance with 34-B M.R.S.A. §5605, Rights and Basic Protections of a Person with an Intellectual Disability or Autism,

    1. Ensuring compliance with the Reportable Events System (14-197 CMR ch. 12),
    2. Ensuring compliance with reporting allegations of abuse, neglect, or exploitation of persons receiving services, in accordance with MRS Title 22, Chapter 958-A and 10-149 CMR ch. 1,
    3. Ensuring compliance with the Home and Community Based Services (HCBS) Settings Rule: please see OADS Training and Resources for more information,
    4. Duration of care (intake/discharge),
    5. Routine and emergency healthcare, and
    6. Medication administration.
  3. Personnel Administration
    1. General written orientation program for all new employees, interns, and volunteers, including but not limited to an overview of the service delivery system as a whole, the availability of peer and family supports and other elements of services; the provider's mission, philosophy, clinical services, therapeutic modalities, policies, and procedures; member’s right to privacy and confidentiality; and safety and emergency procedures general to the provider.
    2. Position-specific orientation and training to all employees, interns, and volunteers, including by not limited to any requirement for a driver’s license, personal insurance limitations, computer proficiency, that a Direct Support Professional (DSP) will receive additional training specific to member needs as addressed in the Personal Plan, ensuring appropriate certification and ongoing training as specified in the MaineCare Benefits Manual, which includes but is not limited to the following: Person Centered Planning Process as outlined in 42 CFR §441.303, Medication Administration Training for those who assist members with over-the-counter and prescribed medication, and cultural competence training relevant to the populations served, including: age, gender, race, religion, culture, and sexual orientation.
  4. Environment and Safety
    1. Structures shall meet current requirements of the Americans with Disabilities Act of 1990, the Rehabilitation Act of 1973, and the Maine Human Rights Act. New construction, renovation, remodeling or repair shall be in full compliance with the Americans with Disabilities Act of 1990, the Rehabilitation Act of 1973, and the Maine Human Rights Act. All structures used in the delivery of waiver services shall be maintained in good repair, free from danger to the member’s health or safety and shall be appropriate to the services provided- furnishings and equipment appropriate to the members’ age and physical conditions rooms and areas are clean, appropriately lit, and adequately heated and ventilated based on the needs of the members, the square footage of are appropriate and adequate for the level of privacy, purpose of the space and to accommodate users, utilities are maintained in good repair and in a manner consistent with applicable codes, and a storage area that shall provide secure space used for the proper storage of potentially harmful materials (i.e. chemicals, medications, and firearms).
    2. Fire and safety inspections are conducted by authorized representatives of organized fire departments, by the State Fire Marshall's office, or code enforcement officers.
    3. Emergency Management Plan addresses the event of loss of essential services such as electricity, water, and heat, as well as evacuation plans.
  5. Quality Management
    1. Written policies governing the development and maintenance of an effective quality management program to ensure quality service delivery consistent with federal and state laws and regulations.
    2. The program shall:
      1. identify areas determined by the provider to be critical to quality service provision,
      2. describe goals set by the provider to improve services or service delivery and shall describe indicators to measure achievement of the goals,
      3. include ongoing, year-round, regular activities to measure goal achievement, and
      4. include a component describing the system to monitor compliance with federal and state laws and regulation.