You C Can Do n Do THA HAT? MAKING THE MOST OF BUDGET AUTHORITY UNDER THE HCBS WAIVER PRESENTED BY: ROBIN E. COOPER, NASDDDS
Housekeeping… Please, please, please cell phones muted, off, buried, drowned or whatever it takes to limit interruptions The doors are not locked so if you need/want to leave please feel free to do so I have absolutely no control over heating/cooling issues Please DO ask questions and add comments during the presentation (I like that because its evidence that someone is awake besides me!) R. COOPER, NASDDDS 4/2019 2 2
What we will cover Acronym review Waiver 101 condensed HCBS waiver "can'ts“/"havetas“ General HCBS waiver flexibility ◦ Personal assistance retainer option example Quick review of waiver budget authority Specific HCBS waiver budget authority flexibility ◦ Defining services ◦ Individual directed goods and services Discussion, “CMS, may I?” 3 R. COOPER, NASDDDS 4/2019 3
Secret Acronym Key CMS Centers for Medicare and Medicaid EPSDT Early Periodic Screening, Diagnosis and Treatment HCBS Home & Community Based Services HCB CMS regulations about where services are provided; requirements for PCP and conflict free case Settings Rule management IDEA Individuals with Disabilities Education Act IDGS Individual Directed Goods and Services PCP Person-centered planning SMD State Medicaid Director SPA State plan amendment 1915(c) Home and community-based services waiver 1915(i) State plan HCBS 1915(j) Self-directed personal assistance services under the Medicaid State plan 1915(k) Community First Choice Technical Guide Application for a §1915(c) Home and Community-Based Waiver [Version 3.6, January 2019] Instructions, Technical Guide and Review Criteria, Release Date: January 2019, R. COOPER, NASDDDS 4/2019 4 4
And a quick look at what a few these terms mean… Medicaid funding authorities for home and community-based services: 1915(c) Home and community-based services waiver 1915(i) State plan HCBS 1915(j) Self-directed personal assistance services under the Medicaid State plan 1915(k) Community First Choice State plan: State agreement with CMS about what health and medical services the state will cover Varies considerably state-to-state EPSDT Early Periodic Screening Diagnosis and Treatment: Coverage of any and all Federally allowable State plan services for kids R. COOPER, NASDDDS 4/20195 5 5
Why look mainly at the HCBS waiver? Because CMS uses and refers to the HCBS Waiver Application and Technical Guide when giving guidance on other funding streams These documents provide good information on establishing budget authority and understanding what supports and services can be covered The Application for a §1915(c) Home and Community-Based Waiver [Version 3.6, January 2019] Instructions, Technical Guide and Review Criteria, Release Date: January 2019 , known as the Technical Guide provides information on decision-making around “goods and services”** not otherwise specified in services definitions ◦ https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/downloads/hcbs-waivers- application.pdf ◦ https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/downloads/technical-guidance.pdf ** More later… R. COOPER, NASDDDS 4/2019 6 6
Waiver 101: The Lightening Round Version Section 1915 (c) of the Social Security Act allows CMS to waive regulations allowing states to use Medicaid money for HCBS that otherwise would have paid for an institutional placements: NF, ICF/IID, hospital States must apply to CMS using a (big)** application describing who and how many people they will serve, what services, what providers, how health, safety and quality are assured and cost estimates States can elect self-direction, but not required CMS reviews and approves the application initially for 3 years/renewal for 5 years **The guide to the waiver application is 314 pages…. R. COOPER, NASDDDS 4/2019 7 7
Waiver “can’ts”…(and some cans) 1. Can't give cash directly to a waiver participant or parent…(but budget control/participant-directed services are perfectly permissible) (can give cash to an individual using the State plan 1915(j ) Self-directed Personal Assistance Services option) 2. Can't pay for room and board with Medicaid money (except for respite, nutritional supplements, or one meal/day-like Meals on Wheels or as a part of live-in caregiver option) 3. Can't pay for exactly the same stuff under the waiver that is covered by the Medicaid state plan until you first use those services, but, ◦ Can provide for “extended State plan services” for adults, again once Medicaid State plan services are used up ◦ Can “redefine” services so they aren’t quite the same as State plan services and then cover them under a waiver R. COOPER, NASDDDS 4/2019 8 8
Waiver “can’ts” 4. Can't pay for services that are covered under the Rehabilitation Act or IDEA…that is services that a vocational rehabilitation agency are required to cover or services that are part of the public education system’s responsibility to deliver 5. Can’t pay for services for Medicaid-eligible kids that should be covered by EPSDT, coverage all mandatory and optional Medicaid services for kids (see acronym list) 6. Can't cover a few services such as recreation**, guardianship, institutional services other than respite, general home repair (but you can repair housing accessibility modifications) 7. Can't serve folks who don't meet the waiver and Medicaid eligibility criteria in the approved waiver ** We call it the “no fun” rule…but “therapeutic” recreation and assistance to participate in recreational activities are okay R. COOPER, NASDDDS 4/2019 9 9
Waiver (and all the other authorities) Can’ts: HCB Settings Regulations HCBS are not permissible in: 8. Settings that are located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment; 9. Settings that are in a building located on the grounds of, or immediately adjacent to, a public institution; 10. Any other settings that have the effect of isolating individuals receiving Medicaid HCBS from the broader community of individuals not receiving Medicaid HCBS For chapter and verse on the rules: https://www.medicaid.gov/medicaid/hcbs/training/index.html https://www.medicaid.gov/medicaid/hcbs/guidance/settings/index.html R. COOPER, NASDDDS 4/2019 10 10
” Non-negotiable requirements: Waiver “havetas” The average cost per person ** under the waiver can’t be more than the average cost per person in an institution: Community $ < or = Institution $ Financial accountability for how waiver money is spent, for whom and what services. State has a formal system to monitor health and safety Individual costs can vary widely and states can cap the total amount available to any one individual (and this only applies to the 1915(c) HCBS waiver) R. COOPER, NASDDDS 4/2019 11 11
Non-negotiable requirements: Waiver “havetas” Everyone has an individual plan of care developed using a person- centered planning process done by qualified individuals Necessary safeguards have been taken to protect health and welfare ◦ Provider standards ◦ Incident management ◦ Medication reviews ◦ Use of restraints R. COOPER, NASDDDS 4/2019 12 12
Waiver “havetas” Individual rights ◦ Freedom of choice of providers. People can choose any provider they want that is qualified , under state rules, to do the work. ◦ Portability of funding-the benefit /budget “belongs” to the individual, not the provider ◦ Informed of choice of institutional or community-based services. Waiver services must comport with the HCB settings rules Case management must be free of conflict of interest R. COOPER, NASDDDS 4/2019 13 13
The HCBS Waiver Can’t/Haveta List Can’t Haveta 1. Can't give cash directly to a waiver participant 1. Cost-neutrality or parent 2. Financial accountability 2. Can't pay for room and board with Medicaid 3. Formal system to monitor health and safety 3. Can't pay for exactly the same stuff under the 4. Necessary safeguards have been taken to protect waiver that is covered by the Medicaid state health and welfare plan until you first use those services 5. Freedom of choice of providers 4. Can't pay for services that are covered under 6. Individual person-centered plan of done by qualified the Rehabilitation Act or IDEA individuals 5. Can’t pay for services for Medicaid-eligible kids 7. Portability of funding-the benefit /budget “belongs” to the individual, not the provider that should be covered by EPSDT 8. Informed of choice of institutional or community- 6. Can't serve folks who don't meet the waiver and Medicaid eligibility criteria in the approved based services 9. Waiver services must comport with the HCB settings waiver rules 7. Can’t deliver/pay for HCBS in setting that do not 10. Case management must be free of conflict of interest meet the settings rules R. COOPER, NASDDDS 4/2019 14 14 14
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