An introduction to the world of Medicaid home and community-based services…As of may, - PowerPoint Presentation

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An introduction to the world of Medicaid home and community-based services…As of may, 2017***

Medicaid Home and Community Based Services Waivers

***subject to change…

NASDDDS

National Association of State Directors of Developmental Disabilities ServicesSlide2

My disclaimers..

"

I have to tell you, it's an unbelievably complex subject…Nobody knew

that

health care

could be so complicated.“ ******President Trump

NASDDDS 5/17

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We’ll Cover:

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Quick overview of Medicaid1915(c)Home and Community-Based Services (HCBS) WaiversBasics of the 1915(c) waiver requirements

HCBS 2014 regulations

Settings, conflict of interest, person-centered planningThe waiver application and Technical Guide (waiver manual)Shallow dive into some other waivers that are HCBS-related optionsN.B.: We won't be covering any of the HCBS state plan options such as 1915(i)/(j)/(k)—we’ll save those for another day

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Medicaid: A Quick Review

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But really

, it’s not so hard!!

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Mandatory and Optional Eligibility Groups: People

Mandatory and Optional Benefits: Services

Supporting rules and payment requirements: Premises of the program

Waivers, demonstrations, exceptions to the “regular” business

Individualized services and supports

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Medicaid ...

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Began in 1965 to pay for health care to welfare recipientsAll 50 states and DC participate—but they do not have to

Jointly administered

by

the states and the federal Centers for Medicaid and Medicare Services (CMS)Jointly funded by the states and federal governmentFeds "match" state contribution on an annually determined formula called the matching rate based on the state's economic pictureThe Federal share is called Federal Financial Participation (FFP) or sometimes FMAP (Federal Medical Assistance Percentage)The

state share is called state match6Slide7

State/Federal Partnership

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Medicaid now is WAY more than it’s original intent of health care for low-income individuals and now is the

major source of financing for long term community supports and

services***The state operates Medicaid under it's State Plan and other “authorities” such as waivers The state can change coverage, eligibility and the scope and amount of services as neededThe state submits State plan amendments (SPAs) or waiver applications covering different services which CMS reviews and approves

***In 2013, Medicaid outlays for institutional and community-based LTSS totaled just over $123 billion, accounting for about 28 percent of total Medicaid service expenditures that year. (KFF.org)7Slide8

Other Medicaid Tidbits…

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State plan services are an entitlement to anyone who is eligible—based on meeting any specific eligibility criteria and what is called “medical necessity” (but waivers are different as we will see)

Children, under the provisions of EPSDT *are entitled to ALL mandatory and optional

services even if the state does not specifically cover them for adults such as:

Autism treatmentsDental carePersonal careTraining family on treatmentsSkilled nursing services * Early P

eriodic Screening, Diagnosis, and Treatment8Slide9

Mandatory services

Optional servicesNASDDDS 5/17

In/outpatient

hospital

Physician, midwife, and nurse practitioner

Nursing homeHome healthScreening and treatment (EPSDT) for kids under 21

Family PlanningRural health clinics, federally qualified health centersPersonal careICF-IIDPrescription drugsTherapies-OT/PT/SpeechTargeted case managementMental Health ServicesHome and community-based State plan services1915(i) State plan HCBS1915(k) Community First Choice1915(j) Self-directed Personal careWaiver options1915(c) HCBS waiver

1115 Research and demonstration waiver1902(a) voluntary managed care waiver1915(b)(3) Freedom of Choice waiver1915(b)(4) Selective contracting

States can choose to cover these services but are not required to do so by federal regulations in order to participate in Medicaid EXCEPT FOR KIDS!!

Medicaid Services

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A bit more on autism services

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Many states had covered autism treatments for kids under the HCBS waiversCMS issued guidance indicating states

must

cover autism treatment services under “regular” Medicaid under the EPSDT regulations*,

thus, autism services to children can no longer be covered as a waiver serviceThe state can cover these services as preventive, therapy or under the “other licensed practitioner” categoriesStates can choose what treatment modalities to cover—does not have to be Applied Behavioral Analysis, CMS noted: “CMS is not endorsing or requiring any particular treatment modality for ASD.”

States have removed autism services from their HCBS waivers and submitted new SPAs for autism services—California, Indiana, Michigan, Montana, Minnesota-and more*http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-07-14.pdf10Slide11

What is a waiver?

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11A waiver means that the regular

Medicaid rules are

“waived”,

that is, not applied The waivers allow for Medicaid to be used in ways that might otherwise not “comport” with certain regulationsWaivers are typically intended to give states flexibility to serve new populations and/provide services in innovative waysSlide12

Quick look at pother types of waivers

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1115 Research and demonstration waiverOften used for managed care

Allows states considerable latitude in designing Medicaid options

1915 (b) waivers

1915(b)(3) Freedom of Choice waiver1915(b)(4) Selective contracting1902(a) voluntary managed care waiverSlide13

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Understanding the Pillars of the HCBS Waiver

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What is a HCBS Waiver??

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The HCBS waiver began in 1981 as a means to correct the “institutional bias” of Medicaid fundingThe “bias” is that individuals could get support services

if

institutionalized, but if they wanted to return to the community they could not get

Medicaid-funded home and community-based services

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What is a HCBS Waiver??

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Section 1915 (c) of the Social Security Act was changed to allow states to ask for waivers of existing Medicaid regulation**The idea is that states can now use the Medicaid money for community services that would have been used for the person in an institution

Thus, getting HCBS waiver services

is tied

to institutional eligibility**Waiver regulations also found at: 42CFR441.300-310

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Institution/HBCS link

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This does NOT mean you have to go to an institution or want to go to an institution—just that you could be eligible for services in an institution

The waiver means you can

choose

services in the community instead of institutional services

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Why bother having waivers?

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Bang for the buck!Medicaid is a matching program where the feds and the state share the financial burden

The state pays part of the cost and the feds “match” what the state

pays making state dollars go further

Matching rates are a minimum of 50% up to 75% in a few states

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State/federal partnership

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The Centers for Medicare and Medicaid Services (CMS) provides states with an

web-based application

to fill out (called the waiver format or template)

The state fills in the template, submits the plan to CMSBecause the waiver is a Medicaid program, the Single State Medicaid Agency must submit the application, but another agency/division can run the waiver day-to-day (operating agency)

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State/federal partnership

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application (sometimes after considerable negotiation)HCBS Waivers are approved for a three year period initially and can be renewed for five-year periods

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The Waiver Application has….

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10 Appendices =

125

pages..

and a 339 page technical guide to fill it out!Appendix A: Waiver Administration and Operation

Appendix B: Participant Access and Eligibility Appendix C: Participant Services Appendix D: Participant-Centered Planning and Service Delivery Appendix E: Participant Direction of Services Appendix F: Participant Rights Appendix G: Participant Safeguards Appendix H: Quality Management Strategy Appendix I: Financial Accountability Appendix J: Cost Neutrality Demonstration

…So let’s have some sympathy for those

who have this job!

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IMPORTANT!!!!!

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The one essential item you

cannot do without….it’s the waiver

https

://

www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/downloads/technical-guidance.pdfSlide22

Who can a HCBS waiver serve?

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The person must be eligible for Medicaid, according to your state rules, and,

Meet what’s called the level of care (LOC) for nursing home,

ICF-IID*,

hospital or other Medicaid-financed institutional careStates can cap the number of people they plan to serveStates can “target’ specific groups by age, diagnosis or condition

*Intermediate care facility for individuals with intellectual disabilities22Slide23

Level of Care (LOC)

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LOC means that the person has needs that could make them eligible for institutional care “but for the provision of HCBS services”States

propose the LOC process which must be identical to

or equivalent to

the process used for the institution CMS approves the processThe person (or parent or guardian) also must be offered the option of institutional care--even if there’s no way they’d ever want it—because under Medicaid people have the right to choose an institution instead of the community

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But—time out…must states have institutional capacity?

NASDDDS 5/17While states technically must

offer institutional services, states do NOT have to have any institutional “beds” within the stateStates without any institutions would need to have an agreement with another state that individuals who really wanted an institution could go out-of-state

Individuals do not have an entitlement to specific institution—just the right of access

Oregon has NO ICF/IID beds at all—(and no demand either…)

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Waiver cans and can’ts

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Okay, it is a federal program and there are some rules…so

let’s first

take a look at what you

can’t do, so we know what we can do with a waiver…

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Waiver can'ts

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HCBS waivers are federal programs and there are some rules...so you:

Can't

give cash directly to a waiver

participant or parent…(but consumer-directed and controlled services are perfectly permissible)Can't pay for room and board with Medicaid money (except for respite, nutritional supplements, or one meal/day-like Meals on Wheels)

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Waiver can'ts...

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Can't pay for exactly the same stuff under the waiver that otherwise is covered by

a Medicaid

card until you first use up

Medicaid card servicesFor children this means ANY mandatory AND optional State plan service CANNOT be covered by the HCBS waiver (more to come on this)Can't pay for services that Vocational Rehabilitation or the public schools (IDEA) are supposed to pay forCan’t do general home repair with waiver dollars

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Waiver can’ts

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Can't cover a few services such as recreation**, guardianship or institutional services other than respiteCan't serve folks who don't meet the Medicaid eligibility rules your state got approved under their waiver

**but “therapeutic” recreation and community participation activities are okay…

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And there are requirements...

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These are things the state MUST do. The state must promise the feds that

the

waiver

is cost-neutral.This means the state spends the less than or the same amount on HCBS as they would have spent for institutional services—on average. This means the average cost per person under the waiver can’t be more than the average cost per person in an ICF/IID.

Community $ < or = Institution $Individual costs can vary widely and states can cap the total amount any one individual can spend=29Slide30

And within

each Appendix…

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The state must describe who does what

and how the state will meet all the requirements of the HCBS waiver

programPerformance measures on key assurances and “sub-assurances” that the state must agree to This includes

describing: Methods for discovering if the state is meeting the requirement (discovery) which includes data collection, sampling methods and analysis to demonstrate compliance with assurancesRemediation of issues discoveredSystem improvement…….all of which we will go into much more detail in our webinar on quality and outcomesSlide31

But here’s a quick look at theWaiver Quality Assurances

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Assurance - The State demonstrates that it implements the processes and instrument(s) specified in its approved waiver for evaluating/reevaluating an applicant's/waiver participant's level of care consistent with care provided in a hospital, NF, or

ICF/IID

Assurance- The State demonstrates it has designed and implemented an effective system for reviewing the adequacy of service plans for waiver participants.

Assurance - The State demonstrates that it has designed and implemented an adequate system for assuring that all waiver services are provided by qualified providers.31Slide32

Waiver Quality Assurance

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Assurance-- On an ongoing basis the state identifies addresses and seeks to prevent instances of abuse, neglect and exploitation.Assurance- State financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver

Assurance – The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.

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Waiver Assurances

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And those six “basic” assurances come with about 17 “sub-assurances”States must develop data collection and report information that shows compliance with all these assurances

Demonstrating compliance with these assurances is

required

If states do not meet an 85% threshold of compliance, CMS will institute a plan of correction

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These assurances mean….

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Everyone has an

individual plan of care

developed by qualified individuals

Must have

provider standards, designed by the state and approved by CMS, that make sure the people giving support know what they are doing Necessary safeguards have been taken to protect the health and welfare

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Freedom of choice

of providers. This means people can choose any provider they want that is

qualified

, under state rules, to do the work.

Portability of funding.

Medicaid money “follows the person”, i.e. the benefit “belongs” to the individual, not the providerInformed choice of institutional or community-based services.

More things the state MUST do:

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More things the state MUST do:NASDDDS 5/17

Financial accountability

for all funds. This means the state has to know how the money is spent, for what people and what services.

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More things the state MUST do:

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State has a

formal system to monitor health and safety.

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Monitoring

health and safety includes:

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State oversight of the service system and

providers

through visits to consumers and providersGetting information from waiver participants about how they like their services

A formal system to prevent, report and resolve instances of abuse or neglect38Slide39

More things the state

MUST do:

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Operate the waiver

statewide

unless the state has special permission to only have the waiver in some areas. Make sure everyone on the waiver can generally get the same types of services all over the state—called access to service

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More things the state

MUST do:

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Make sure that people with the same type of

assessed needs

get the access to similar levels of supports***—called equity of services

*** of course individualized though the person-centered planning process40Slide41

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And the biggest "

haveta" of all..

States MUST do what they said they were going to do in the waiver application approved.. (but that doesn’t mean the waiver can’t be changed as things change)

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Despite the myriad requirement's there's a lot of room

for creativity

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States can “set” aside waiver capacity for specific groups they want to serve, known as reserve capacity

Although CMS provides guidance and what are called “core services definitions”, states can re-define, rename or completely develop their own service definitions, creating new, innovative services

Can develop creative quality management that really engages stakeholdersCan design “tailored” or “specialty "case managementFamily-focusedBehavioral health focusSlide43

Despite the myriad requirement's there's a lot of room for creativity

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43States decide whom and what to cover and how, so…

Can encourage and support self-direction

Can design employment first focused systems of support (ex. parent-to-parent)

Can design “specialized” waivers for specific groups Can support self-advocacyCan use individual budgetsCan incentivize employmentCan support families in creative ways Can provide for innovative uses of technology to support peopleCan permit ‘non-traditional’ providers (states decide who’s qualified)Slide44

Although the waiver has rules, within those rules

it's up to the state and stakeholders to decide

…..

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The values that underlie your system

Whom you want to serveHow many people you can serveThe processes used to develop individual support plans What supports & services you coverWho can provide those servicesWhat you pay for the services, andHow health, safety and quality are determined

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NEW HCBS rules: The big deal stuff

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HCB Settings Character What is NOT communityWhat is likely not community

What is community

Person-centered planning

Codifies requirementsConflict-free case managementWas just in guidance, now it is in rule:https:www.federalregister.gov/r/0938-AO53

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Coming into compliance

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CMS has termed coming into compliance with the HCB settings requirements “Transition”States have provided CMS with a Statewide Transition Plan (STP)for approval,

“detailing

any actions necessary to achieve or document compliance with setting

requirements”States must be in compliance with settings rules by March 2022 (See: https://www.medicaid.gov/federal-policy-guidance/downloads/cib050917.pdf)

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Before we define HCB Settings character..

Settings that are NOT Home and Community-based:

Nursing facilityInstitution for mental diseases (IMD)Intermediate care facility for individuals with intellectual disabilities (ICF/IID)

Hospital

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Settings PRESUMED not to Be Home And Community-based

Settings in a publicly or privately-owned facility providing inpatient

treatmentSettings on grounds of, or adjacent to, a public institution

Settings with the effect of isolating individuals from the broader community of individuals not receiving Medicaid HCBS

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HCBS setting

requirementsNASDDDS 5/17

Is

integrated in 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 resourcesEnsures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based servicesThe setting is selected by the individual from among setting options including non-disability specific settings and an option for a private unit in a residential setting

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Case Management and Conflict of Interest

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“Providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual must not provide case management or develop the person-centered service plan,

[Providers may be allowed if]

the

State demonstrates that the only willing and qualified entity to provide case management and/or develop person- centered service plans in a geographic area also provides HCBS. In these cases, the State must devise conflict of interest protections …which must be approved by CMS. Individuals must be provided with a clear and accessible alternative dispute resolution process.”

42 CFR §441.301 50Slide51

Person-centered planning**

NASDDDS 5/17The

person-centered planning process is driven by the individualIncludes people chosen by the individual

Offers

choices to the individual regarding services and supports the individual receives and from

whomProvides method to request updates **Language taken directly from the new rules.

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Person-centered

planningNASDDDS 5/17

Conducted to reflect what is important to the individual to ensure delivery of services in a manner reflecting personal preferences and ensuring health and welfare

Identifies the strengths, preferences, needs (clinical and support), and desired outcomes of the

individual

May include whether and what services are self-directed

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Written Plan Reflects

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Setting is chosen by the individual and is integrated in, and supports full access to the greater community

Opportunities to seek employment and work in competitive integrated

settings

Opportunity to engage in community life, control personal resources, and receive services in the community to the same degree of access as individuals not receiving Medicaid HCBS

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The Waiver Application has….

NASDDDS 5/17

10 Appendices =

125

pages..

and a 339 page technical guide to fill it out!Appendix A: Waiver Administration and Operation

Appendix B: Participant Access and Eligibility Appendix C: Participant Services Appendix D: Participant-Centered Planning and Service Delivery Appendix E: Participant Direction of Services Appendix F: Participant Rights Appendix G: Participant Safeguards Appendix H: Quality Management Strategy Appendix I: Financial Accountability Appendix J: Cost Neutrality Demonstration

…So let’s have some sympathy for those

who have this job!

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Secret Acronym Key

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ASD Autism Spectrum Disorder

CMS Centers for Medicare and Medicaid

CFC Community First Choice (1915(k))

EPSDT Early Periodic Screening, Diagnosis and TreatmentFFP Federal Financial ParticipationFMAP Federal Medical Assistance Percentage

FPL Federal Poverty LevelHCBS Home & Community Based ServicesICF/IID Intermediate Care Facility for Individuals with Intellectual DisabilitiesI/DD Intellectual and Developmental DisabilitiesIDEA Individuals with Disabilities Education ActLOC Level of CareSPA State plan amendment1915(c) Home and community-based services waiver55Slide56

Resources

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56Waiver Application:

https

://

www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/downloads/hcbs-waivers-application.pdfCMS HCBS Waiver Guidance:https://www.medicaid.gov/medicaid/hcbs/authorities/1915-c/index.htmlhttps://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/downloads/technical-guidance.pdf