You C Can Do n Do THA HAT? MAKING THE MOST OF BUDGET AUTHORITY - - PowerPoint PPT Presentation

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!)

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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?”

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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,

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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

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Why look mainly at the HCBS waiver?

Because CMS uses and refers to the HCBS Waiver Application and Technical Guide when giving guidance on

• ther 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…

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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

• therwise 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….

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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
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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

• ptional 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

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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

• perated 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

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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)

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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
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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

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The HCBS Waiver Can’t/Haveta List Can’t Haveta

1. Can't give cash directly to a waiver participant

• r parent

2. Can't pay for room and board with Medicaid 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 4. Can't pay for services that are covered under the Rehabilitation Act or IDEA 5. Can’t pay for services for Medicaid-eligible kids that should be covered by EPSDT 6. Can't serve folks who don't meet the waiver and Medicaid eligibility criteria in the approved waiver 7. Can’t deliver/pay for HCBS in setting that do not meet the settings rules

1. Cost-neutrality 2. Financial accountability 3. Formal system to monitor health and safety 4. Necessary safeguards have been taken to protect health and welfare 5. Freedom of choice of providers 6. Individual person-centered plan of done by qualified individuals 7. Portability of funding-the benefit /budget “belongs” to the individual, not the provider 8. Informed of choice of institutional or community- based services 9. Waiver services must comport with the HCB settings rules 10. Case management must be free of conflict of interest

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Lightening Round #2: Budget Authority

• P. 192, Waiver Technical Guide:
• Participant Budget Authority. Under the Budget Authority, the participant has the authority

and accepts the responsibility to manage a participant-directed budget. Depending on the dimensions of the budget authority that are specified in Appendix E-2-b, this authority permits the participant to make decisions about the acquisition of waiver goods and services that are authorized in the waiver service plan and to manage the dollars included in a participant-directed budget.

• Budget authority means the participant has a budget assigned that they an spend for

whichever supports and services the state/stakeholders (with CMS approval) come to agreement are covered by the budget.

• Budget authority means the individual has a budget under his/her control—shocking insight,

no?

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Budget Authority

States have a lot of latitude on how budgets are developed and what supports and services come out of the budget

• Budget may be developed “prospectively” using some type of scored functional

assessment tied to levels of funding

• Budget may be developed “retrospectively” based on and individual person-centered

plan

• Use of a budget may be limited to specific (sets of) services, or could be comprehensive
• May permit exceeding limits established for specific services (as long as within overall

budget)

• Can shift money around within the budget
• Can use the Individual Directed Goods and Services option…more to come on this
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HCBS Waiv iver er Applic lication ion: A Appen endix ix E E-2.b.1 Partic icip ipant D Decision ision M Makin king Author

• rit

ity : When the participant has budget a authority, indicate the decision-making authority that the participant may exercise

• ver the budget. Select one or more:
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Reallocate funds among services included in the budget



Determine the amount paid for services within the state’s established limits



Substitute service providers



Schedule the provision of services



Specify additional service provider qualifications consistent with the qualifications specified in Appendix C-1/C-3



Specify how services are provided, consistent with the service specifications contained in Appendix C-1/C-3



Identify service providers and refer for provider enrollment



Authorize payment for waiver goods and services



Review and approve provider invoices for services rendered



Other Specify:

Now that we’ve done can’t and havetas…

SOME E EXA XAMPLES OF OF W WHA HAT ON ONE CA CAN DO O WITH A H A BUDGE GET

Personal Assistance Retainer Payments

“42 CFR §441.301(b)(1)(ii) provides that waiver services may not be furnished to individuals

who are in-patients of a hospital, nursing facility or ICF/IID. FFP is not available for waiver services while the person is in a hospital, nursing facility or ICF/IID except for temporary short-term respite services delivered in an institution, and personal assistance retainer payments” BUT A state may elect to make retainer payments to personal assistants when the waiver participant is hospitalized or absent from his/her home for a period of no more than 30-days. For waivers offering participant direction, states may permit the use of the retainer to afford direct support workers time off from providing services to their employer.

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Personal Assistance Retainer Payments

This provision:

• Assures that individuals can keep their support staff even while away
• Establishes continuity of support and doesn’t “punish” support staff when their employer is

away—for whatever reason and/or…

• Allows for paid time off??? How novel!!!
• Can be used for any direct support staff agency-based, independent and under a self-directed

model.. BUT

• If an absentee factor is already in a provider’s rate, cannot use this option as the time off is

already paid for See Olmstead Letter #3, Attachment 3-c: https://www.medicaid.gov/Federal-Policy-Guidance/downloads/smd072500b.pdf

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Individual Directed Goods and Services

(IDGS)

Individual Directed Goods and Services

We’ll cover: CMS general guidance about Medicaid services CMS specific guidance on IDGS in the home and community-based waiver

• Core services definition and other CMS guidance
• Other principles for decision-making
• Finding the balance between consumer choice and public duty…

What other states have done Let’s play, “CMS , may I?” Let’s play, “Should I?”

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“The definition of each waiver service must describe in concrete terms the goods and services that will be provided to waiver participants, including any conditions that apply to the provision of the service… The scope of a service may be defined in one of two ways. An exhaustive service definition may be employed…. In the alternative, a service may be defined as to its purpose.” 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, p. 116

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guid idance a about a all w l waiv iver ser ervic ices

When new services are proposed, CMS reviews the proposed service to ascertain whether the service:

• Contributes to the community functioning of waiver participants and thereby avoids

institutionalization;

• Is reasonably related to addressing waiver participant needs that arise as a result of their

functional limitations and/or conditions; and/or,

• Falls within the scope of §1915(c) of the Act and is not at odds with other provisions of the

Act.” [Such as the other resources like schools or vocational rehabilitation agencies that have first responsibility to cover the service/support] Waiver Technical Guide, p.117

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When new services are proposed, CMS reviews the proposed service to ascertain whether the service:

• Contributes to the community functioning of waiver participants and thereby avoids

institutionalization;

• Is reasonably related to addressing waiver participant needs that arise as a result of their

functional limitations and/or conditions; and/or,

• Falls within the scope of §1915(c) of the Act and is not at odds with other provisions of the

Act.” [Such as the other resources like schools or vocational rehabilitation agencies that have first responsibility to cover the service/support] Waiver Technical Guide, p.117

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IDGS (Suggested) Waiver Core Service Definition

Individual Directed Goods and Services are services, equipment or supplies not otherwise provided through this waiver or through the Medicaid State Plan that address an identified need in the service plan (including improving and maintaining the participant’s opportunities for full membership in the community) and meet the following requirements: [emphasis added]

• the item or service would decrease the need for other Medicaid services;
• AND/OR promote inclusion in the community;
• AND/OR increase the participant’s safety in the home environment;
• AND, the participant does not have the funds to purchase the item or service or the item or

service is not available through another source.

Individual Directed Goods and Services are purchased from the participant-directed budget. Experimental or prohibited treatments are excluded. Individual Directed Goods and Services must be documented in the service plan.

Waiver Technical Guide, p. 172

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More official guidance…

In other CMS guidance, State Medicaid Director Letter # 09-007 , November 19, 2009, reiterates the above and adds, IDGS:

• Are able to be accommodated within the participant’s budget without compromising

the participant’s health or safety; and,

• Are provided to, or directed exclusively toward, the benefit of the participant.
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And even more official guidance……

“We also expect that State Medicaid agencies ensure oversight for proper

implementation of the criteria by designing procedures that will effectively govern how participants will reserve funds for the purchase of goods and services, if elected by the State. We expect these procedures to include that the annual reassessment of participants by the State Medicaid agency takes into account purchases of goods and services that substitute for human assistance and any adjustments for the need for human assistance.”

SMD # 09-007, November 19, 2009 https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-11-19-09.pdf

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What other principles might come into play?

Need and (vs.?) want

• Need clean water/Want Pellegrino
• Need reliable transportation/want a Volvo

Equity of access

• Build me a pool
• But I can’t have a pool ‘cause I don’t have a backyard…

Equally effective/cost effective

• Build me a pool
• Join a gym

Cultural considerations

• My caregiver must be the same gender as me

Children and “typical” family purchases vs. items needing special modifications/adaptations

• Buy a swing set
• Buy the adaptive seat swing
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What might be an equitable approach that honors choice and meets the CMS requirements?

• List of (some of?) allowable goods and services?
• Caps on expenditures for IDGS?
• Exception process?
• Who and how managed?
• Prohibitions on certain items/services?
• Better/different review criteria/process?
• All high-cost requests reviewed by committee?
• All “unusual” requests reviewed by committee?
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Interesting options

Massage Adult Dental Adult education Therapeutic Supports and Wellness (gym, yoga) Household appliances Financial literacy/financial management Internet access Equine therapy Technology solutions to independence, self- sufficiency * AbleLink Technologies: Focuses on research and development of innovative cognitive support technologies that enable people with cognitive limitations to live more independent and self- determined lives. (http://www.ablelinktech.com) Ohio: Remote Support**Sensors: Flood, bed , door, window seizure mats – medication dispensers – tooth brush sensors – Motion detectors, monitoring, video, wayfinding apps, voice- activated everything, hygiene aids, self-flushing toilet

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*Leveling the Playing Field: Improving Technology Access and Design for People with Intellectual Disabilities, U of Colorado, Coleman Inst. 2015 **https://www.colemaninstitute.org/wp-content/uploads/2018/01/Coleman-Presentation-Tasse-Wagner-and-Davies.pdf http://dodd.ohio.gov/IndividualFamilies/Pages/TechnologyFirst.aspx

What NY Approved (I/DD):

Camp Adult education Coaching/ education for parent(s), spouse and advocates involved in the person’s self- directed services Health Club Organizational Memberships Clinical services not otherwise available Household Related Items and Services Academic Tutoring Post-secondary transition programs oriented toward employment

https://opwdd.ny.gov/sites/default/files/documents/IDGS_Chart_CMS_Approved_Amendment_01%20%28002%29.pdf

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D.C. Services My Way Waiver: YES!

Allowable Goods and Services shall: 1. decrease the need for other Medicaid services; and/or

• 2. promote inclusion in the community; and/or 3. increase the waiver participant’s safety in the

home environment, and 4. are not currently covered by Medicaid and include:

• Cleaning service from firms or individuals to clean the waiver participant’s personal areas including

bedroom, bathroom, kitchen, etc. • Food preparation service and delivery of prepared foods (but not payment for the food itself). • Transportation services not currently available under Medicaid or the county transportation system related to activities of daily living. • Small electric appliances which allow the individual to safely prepare meals. • Laundry service from a Laundromat or other provider. • Supplies and equipment that decrease the need for other Medicaid services, and/or promote or enhance independence and/or increase the waiver participant’s safety in the home environment, and are not currently covered by

• Medicaid. • The cost of changing locks at the individual’s home, as necessary, when a participant-directed

worker stops working for the individual. ALL ITEMS MUST BE DIRECTLY & CLEARLY RELATED TO MEETING A PERSONAL CARE NEED THAT WOULD BE PROVIDED BY A PARTICIPANT-DIRECTED WORKER (PDW) https://www.consumerdirectdc.com/wp

• content/uploads/2016/02/APPENDIX-B-Allowable-Non-Allowable-

ID-G-S.pdf

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D.C.: NO! Non-Allowable Goods and Services

• Gifts for participant-directed workers (PDWs), family or friends. • Loans to your PDWs. • Food and/or
• ther beverages, nutritional supplements • Entertainment equipment or supplies such as videos, VCR’s,

televisions, stereos, CD’s, DVD’s, audio/video tapes, etc. • Air Conditioners, heaters fans and similar items.

• Electronics such as Ipads, Ipods and cell phones. • Illegal drugs. • Alcoholic beverages. • Tobacco
• products. • Costs associated with travel (airfare, lodging, meals, etc.) for vacations or entertainment. •

Utility, rent or mortgage payments. • Clothing or shoes or other wearing apparel. • Comforters, towels, linens or drapes. • Paint and related supplies. • Furniture & household furnishings. • Cleaning for other household members or areas of a home that are not used as part of the waiver participant’s personal care.

• Household or kitchen appliances such as washers, dryers, dishwashers, refrigerators, freezers. • Exercise
• equipment. • Medications, vitamins/herbal supplements. • Experimental and Prohibited Treatments. •

Laundry detergent and household cleaning supplies. • Vehicle expenses including routine maintenance and repairs, insurance or gas money for a personal vehicle or a family member’s vehicle who performs tasks they are responsible for outside of personal care. • Transportation to work, school, day program or recreational activities. • Landscape and yard work. • Pet care, except for service animals. • Massages, manicures and pedicures. These items may be covered in other states (or some may be covered by another waiver service such as assistive technology)

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So, let’s play ,

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CMS,

MAY I ?

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What do you want to buy or do?

Overarching Considerations The Item, Equipment, Service or Support:

 Is reasonably related to addressing waiver participant needs that arise as a result of their functional limitations and/or conditions; and/or,  Falls within the scope of §1915(c) of the Social Security Act and is not at odds with

• ther provisions of the Act

 Is not otherwise provided through this waiver,  Or through the Medicaid State Plan,  Contributes to the community functioning of waiver participants and thereby avoids institutionalization;

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Overarching Considerations The Item, Equipment, Service or Support

 Addresses an identified need in the service plan (including improving and maintaining the participant’s opportunities for full membership in the community) Meets the following requirements:  The item or service would decrease the need for other Medicaid services;  AND/OR promote inclusion in the community;  AND/OR increase the participant’s safety in the home environment;  AND, the participant does not have the funds to purchase the item or service or the item or service is not available through another source.

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