An Overview Medicaid Final Rules The Centers for Medicaid and Medicare Services CMS made the new rule CMS is the Federal agency that runs Medicaid in all states Published in Federal Register on January 16 ID: 584135
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Slide1
Federal Home and Community Based Service Settings Rules
An OverviewSlide2
Medicaid Final
Rules
The Centers for Medicaid and Medicare Services
(CMS) made
the new
rule
CMS is the Federal
agency that runs Medicaid in all
states
Published in Federal Register on January 16,
2014 and became effective on March 17, 2014Slide3
Main Points of Rules
Defines
and describes home and community based settings under section 1915 (c) waivers and section 1915 (i) state
plans
Sets forth requirements for person-centered planning process and person-centered service
plan
Lays out transition timeframe and
requirementsSlide4
Medicaid Final Rule
s
In Idaho we use Medicaid for
H
ome and
C
ommunity
B
ased
S
ervices
provided
through
State Plans (Section 1915(i)), or HCBS waivers (Section 1915(c
))
Goal of the rule:
Truly community based services
Action to Support Goal:
Medicaid will only pay for services and supports when they are provided in an integrated mannerSlide5
Qualities of a HCBS Setting
Is
integrated
and
supports access to the greater
community
Provides opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based
services
5Slide6
Qualities
of
a HCBS Setting
S
etting is selected by the individual from among options, including non-disability specific settings
Ensures an individual’s rights
of privacy, dignity, respect, and freedom from coercion and restraint
Provides for individual initiative, autonomy, and independence in making life choices
Allows individual choice
about services and supports, and who provides them
6Slide7
Additional Requirements for Provider-Owned
Residential
Settings
Specific
unit/dwelling is owned, rented, or occupied under a legally enforceable agreement such as a lease or other legally enforceable agreement
Same
responsibilities/protections from eviction as all tenants under landlord tenant law of state, county, or city or other designated
entity
Each individual has privacy in their sleeping or living unit
Units
have lockable entrance doors, with appropriate staff having keys to doors as needed
7Slide8
Additional Requirements for Provider-Owned Residential Settings
Choice of
roommate
Freedom to furnish or decorate the space according to the lease
agreement
Individuals have freedom and support to control their schedules and activities including access to food at any
time
Individuals may have visitors at any
timeSetting is physically accessible to the individualSlide9
Settings Excluded from the Rule
Nursing facilities
Institutions for mental diseases, intermediate care facilities for individuals with intellectual disabilities (ICF/IID)
Hospitals providing long-term care servicesSlide10
Settings that May Isolate
Some settings are presumed to have institutional qualities and will not meet the rule’s requirements for home and community-based settingsSlide11
Settings that May Isolate
Settings that have the following qualities might be isolating:
Designed
specifically for people with disabilities, often for people with a certain type of disability
Individuals
in the setting are primarily or exclusively people with disabilities, and are served mostly by on-site staffSlide12
Settings that May Isolate
Other things to consider:
If
the setting is designed to provide multiple types of services and activities on-site
If
people have limited interaction with the broader
community
If
interventions and restrictions are used that are typical in institutional Slide13
Settings that May Isolate
Examples of settings that
may isolate
:
Farmstead or disability-specific farm
community
Gated/secured
community for people with
disabilitiesResidential SchoolsMultiple settings co-located and operationally related
CMS will be providing further guidance with examples of non-residential settings that isolateSlide14
Person
Centered
Planning
Person centered planning has been part of the delivery of services to children and adults with disabilities for many
years
For the first time, the HCBS rule puts the requirements for person-centered planning into regulation – known in the HCBS rule as “person centered service planning.”Slide15
Person Centered Service Planning
The individual may invite anyone they want. Interpreters or communication device should be provided if needed
Meeting must be held in a manner that respects the individual’s culture and is conducted in a language the individual understands
It should be clear how conflicts or differences among team members will be resolvedSlide16
Person Centered Service Planning
The process should offer the individual choices about the types of services they want, where they want them provided, information on residential options, where they spend their day, and why those choices were made
All those providing services to the individual must sign off on the individual’s plan that they have reviewed the individual’s plan
The plan must be changed or updated at the individual’s request, but must be renewed at least annuallySlide17
Person Centered Service Planning
The written plan should include
:
Options presented to the individual about where to live, what was chosen, and why
Where the individual chose to receive other services, like supported employment
The individual’s strengths, preferences, and needs
The supports needed, both paid and unpaid
Things the individual wants to accomplish (their goals) and how they will know they have achieved them (outcomes)Slide18
Person Centered Service Planning
The plan must
also:
Be written in plain language that the individual
understands
Note any risks the individual might have and plans for dealing with
them
Include the name of the person responsible for making sure the plan is followed
Include the signatures of everyone who participated, and everyone should get a copySlide19
Changing the Setting or Service
Sometimes
, in order for a person with a disability to be well-supported and safe in the community,
plan changes must be made
. For example, some people cannot have unlimited access to food because of
risk
to their health. If an individual needs supports or changes
made, these
need to be written into the person-centered plan.Slide20
Transition
Plan
States
must submit transition plans to
the Centers for Medicaid and
M
edicare (CMS) that
outline the changes to
the HCBS program to gain compliance with the new regulationsA State must provide at least a 30-day public notice and comment period and two statements of public notice and input
procedures on this plan
20Slide21
Transition Plan
The State must consider and modify the plan to account for public comment
If a state substantively amends the plan, the new plan must be put out for public comment
21Slide22
Public Comment
The
draft Idaho State Transition Plan for Home and Community Based Services and Settings
closed public comment on November 2, 2014.
But….
After the November
2, 2014 public
comment deadline the transition plan will be modified based on public comment and posted again for public comment in January 2015Slide23
Things to Think About
What
are necessary supports and settings for community integration?
What
does
“having
a meaningful
day”
really mean? How can an HCBS program support how an individual defines a meaningful day?
How
does a program maintain the idea that community integration may look different for everyone
?
How
can an HCBS program support community integration, foster friendships and connections, ensure self-determination, and encourage independence? Slide24
Things to Think
About
If
a person with a disability values the interactions they have with other people with disabilities, how can those relationships be fostered in such a way that it does not promote segregation?
In fostering independence and integration, how does an HCBS program maintain the flexibility to meet the desires of an individual?
For example, if a person does not enjoy being social every day and would not like to have supported volunteer activities out in the community, but would prefer to quietly feed the ducks with other people in the park, how can a program support that version of community integration? Slide25
Things to Think About
Where
are
HCBS provided now?
Are
Medicaid-funded HCBS services currently provided in excluded institutional settings? Are they provided in settings presumed to be institutional under the new regulations?
For
example, are there group homes owned by a provider that also has ICF-I/IDs? Nursing homes? Are these group homes on the same property as the institutional
setting?
Are
there group homes owned/operated by the State on or adjacent to
institutions?
Is
HCBS provided in settings that have the effect of isolating individuals?
Is
the setting designed specifically for people with disabilities, and often even for people with a certain type of disability? Slide26
Things to Think About
Is
the setting primarily or exclusively people with disabilities and on-site staff provides many services to them?
Are multiple types of services and activities on-site, including housing, day services, medical, behavioral and therapeutic services, and/or social and recreational activities?
Do people in the setting have limited, if any interaction with the broader community?
Do the settings use/authorize interventions/restrictions that are used in institutional settings or are deemed unacceptable in Medicaid institutional settings (e.g., seclusion)Slide27
Things to Think About
What
needs to change in the current person-centered planning process to be compliant with the regulations and to foster community integration, self-determination, and independence? This would include changes to the role of the individual representative.
The above questions
are
a starting point for the broader
discussion.
Once there is an understanding about what an HCBS program should look like, with some understanding of what is possible, the next step is identifying which aspects of the current program need to change.
NHeLP
| National Health Law Program | August 28, 2014 Slide28
Intention of the Rule
Support people with disabilities to have lives like people without disabilities
Provide opportunities for true integration, independence, choice and self-determination in all aspects of life – where people live, how they spend their days, and real community membership
Ensure quality services that meet people’s needs and help them achieve
goals they have identified through real person-centered planning
28Slide29
Additional Resources
CMS Home and Community Based Services Rule and Fact Sheets
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Home-and-Community-Based-Services/Home-and-Community-Based-Services.htmlSlide30Slide31
For More Information:
Christine Pisani
Executive Director
Idaho Council on Developmental
Disabilities
E-mail:
Christine.Pisani@icdd.Idaho.gov
Phone
: 208-334-2178Toll Free: 1-800-544-2433Website: icdd.idaho.gov