1915(c) home and community-based services (hcbs) waiver ... · pds - understanding federal...
TRANSCRIPT
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1915(c) Home and Community-Based
Services (HCBS) Waiver Redesign
Town Hall
Commonwealth of Kentucky
Cabinet for Health and Family Services
June 2019
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Introductions
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Introductions and Housekeeping
• Presenters:
– Pam Smith, Director of the Division of Community
Alternatives (DCA)
– April Lowery, DCA Branch Manager & DMS PDS
Workstream Lead
– Alisha Clark, DCA Branch Manager & DMS Case
Management Workstream Lead
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Town Hall Agenda
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Town Hall Agenda
• Purpose of the Town Halls
• Public Comment Summary and Response
• Review of Selected Waiver Topics
• Anticipated Implementation Milestones and Timeline
• Opportunities for Future Stakeholder Engagement
• Additional Resources and Closing Statements
• Question and Answer Session
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Purpose of the Town Halls
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Purpose of the Town Halls
The purpose of today’s town hall is to:
Share a summary of the 1915(c) HCBS waiver amendment
public comment period conducted in Spring 2019. 1
Provide additional information and explain waiver policy
changes stakeholders care most about. 2
Communicate next steps and upcoming milestones of
1915(c) HCBS waiver redesign. 3
Answer stakeholder questions. 4
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Public Comment Summary and
DMS Response
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Public Comment Summary and Response
Start of Comment Collection End of Comment Collection
3/15/2019 4/15/2019
By Type # of Comments % of Total
Participant 12 3%
Provider 175 39%
Caregiver 222 50%
Other Stakeholder 38 9%
TOTAL 447 100%
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Public Comment Summary and Response (continued)
Top 4 Topics Focused On: # of Comment % of Total
Covered Services 558 39%
Participant Directed Services 301 21%
Case Management 206 14%
Payment and Rate Setting 102 7%
TOTAL 1441 81%
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Public Comment Summary and Response (continued)
• You can find the DMS response to public
comments on the DMS Division of Community
Alternatives website.
https://chfs.ky.gov/agencies/dms/dca/Pages/
default.aspx
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Public Comment Summary and Response (continued)
• Don’t see your comment?
– DMS grouped similar comments when answering
with the same response.
– If you need a more individualized response or the
response did not address the comment, please
reach out to DMS at
– Please note questions submitted during public
comment will be addressed in upcoming FAQs.
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Selected Waiver Topics
Patient Liability
Participant Directed Services
Case Management
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Patient Liability
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Patient Liability – Stakeholder Feedback
Patient Liability is money some participants are asked to
pay toward waiver services if their income is
over the monthly limit required to qualify.
Stakeholder Feedback:
Based on stakeholder feedback collected in
Summer 2018, DMS has changed the way it
calculates a participant’s patient liability.
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Patient Liability – 1915(c) HCBS Waiver Policy Change
• DMS increased the amount of income protected for personal use to
reduce or eliminate patient liability for a majority of participants:
• If a participant’s monthly income does not go over $2,314.92, they will
NOT have to pay patient liability to Medicaid
• This change takes effect December 1, 2019.
• Questions: Call DCBS at 855-306-8959.
Current Patient Liability
Policy
Future Patient Liability
Policy
100% SSI Federal Benefit
Rate (FBR) or $771.64 per
month for 2019
300% SSI Federal Benefit
Rate (FBR) or $2,314.92 per
month for 2019
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Participant-Directed Services
(PDS)
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PDS – Stakeholder Feedback
Stakeholder Feedback:
• A large portion of stakeholder comments were in
regard to PDS; particularly the implementation of
the new Legally Responsible Individuals (LRI)
policy.
• Participants suggested being allowed to waive
certain crimes that may appear on background
check as participants select their PDS worker.
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PDS – Overview
DMS made several updates to the PDS service delivery
model, including:
Clarified when it is appropriate for LRIs to serve
as PDS employees
Updated background check requirements for PDS
employees
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PDS - Understanding Federal Requirements
• For LRIs to be paid as PDS employees, DMS must have and apply
criteria to establish that participant’s needs meet what the Centers for
Medicaid and Medicare Services (CMS) refers to as “extraordinary care.”
• An LRI applying to be a PDS employee must meet the criteria set in the
proposed waivers. The criteria is slightly different if the waiver participant
is a child (under 18 years old) versus an adult (18+ years old).
• LRIs are responsible for making decisions in the best interest of the
participant. The criteria are necessary to limit the possibility of conflicts of
interest that may arise when the LRI is paid to provide care.
Source: Centers for Medicare and Medicaid Services, Application for a 1915(c) Home and Community-Based
Waiver. Instructions, Technical Guide and Review Criteria. January 2019. page 108-112
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PDS - Who Is a Legally Responsible Individual (LRI)?
Definition: A person who has a legal obligation under the provisions of
state law to care for another person. Legal responsibility is defined by
state law, and generally includes parents (natural or adoptive) of minor
children, legally-assigned caretaker relatives of minor children, and
sometimes spouses.
DMS defines an LRI in the following ways:
Minor Child
(Younger than Age 18)
Adult
(Age 18 or older)
• Parent
• Stepparent
• Adoptive parent
• A Kentucky Court Appointed
Legal Guardian
• Spouse
• A Kentucky Court Appointed
Legal Guardian
Source: Centers for Medicare and Medicaid Services, Application for a 1915(c) Home and Community-Based Waiver.
Instructions, Technical Guide and Review Criteria. January 2019. page 108
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PDS – Federal Definition of Extraordinary Care
Source: Centers for Medicare and Medicaid Services, Application for a 1915(c) Home and Community-Based
Waiver. Instructions, Technical Guide and Review Criteria. January 2019. page 109.
CMS Definition of “Extraordinary Care”:
“By extraordinary, CMS means care exceeding the range of activities
that a legally responsible individual would ordinarily perform in the
household on behalf of a person without a disability or chronic
illness of the same age, and which are necessary to assure the
health and welfare of the participant and avoid institutionalization.”
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PDS – Step 1 for a Minor Child
STEP 1 OF 2: THE MINOR CHILD’S NEEDS
Only ONE of the criteria below must be met to proceed to Category 2.
Criteria 1: The child’s dependency in performing activities of daily living (ADLs) must be directly related to his or her disability and exceed that of his or her age matched peers.
• Example: A child of seven years who still needs help using the bathroom, as a direct result of a disability.
Criteria 2: The child demonstrates destructive or injurious behaviors exceeding that of his or her age matched peers and such behaviors represent a risk of serious injury or death to self or others.
• Example: A child becomes angry and, due to a disability, is unable to control their anger and tends to hit others with an object or part of their body.
OR
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PDS – Step 2 for a Minor Child (continued)
STEP 2 OF 2: THE CHILD AND/OR CAREGIVER’S SITUATION
Only ONE of the four criteria must be met.
Criteria 1: The child’s care needs have reduced or eliminated the legally responsible individual’s ability to maintain paid employment in the past 12 months and there is not an alternative caregiver who is functionally able to provide care.
Criteria 2: The legally responsible individual can demonstrate attempts within the first 30 days to recruit a qualified provider (traditional or PDS) but cannot secure one.
OR
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PDS – Step 2 for a Minor Child (continued)
STEP 2 OF 2: THE CHILD AND/OR CAREGIVER’S SITUATION
Only ONE of the four criteria must be met.
Criteria 3: The minor child has a communication barrier exceeding that of his or her age matched peers that impacts his or her ability to effectively communicate needs and wishes.
Criteria 4: The minor child has a sincerely held religious belief and cannot secure a provider (traditional or PDS) who is culturally competent or shares the same religion.
OR
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PDS – Process for Approving LRI PDS Workers for Minor
Children
• Assessed care needs
• Display of Destructive or Injurious Behavior
Step One: Demonstrate Need for Extraordinary
Care
• Employment
• Provider Availability
• Communication Barriers
• Religious Beliefs
Step Two: Demonstrate Situational Need for LRI as PDS Worker
Approve Eligibility of LRI as PDS Worker
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PDS - Criteria for Adults
Criteria 1: The adult’s care needs have reduced or eliminated the legally responsible individual’s ability to maintain paid employment in the past 12 months and there is not an alternative caregiver who is functionally able to provide care.
Criteria 2: The legally responsible individual can demonstrate attempts within the first 30 days to recruit a qualified provider (traditional or PDS) but cannot secure one.
STEP 1 OF 1: THE ADULT AND/OR CAREGIVER’S SITUATION
Only ONE of the criteria below must be met.
OR
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PDS - Criteria for Adults (continued)
Criteria 3: The adult has a communication barrier that impacts his or her ability to effectively communicate needs and wishes to be a care provider.
Criteria 4: The adult has a sincerely held religious belief and cannot secure a provider (traditional or PDS) who is culturally competent or shares the same religion.
STEP 1 OF 1: THE ADULT AND/OR CAREGIVER’S SITUATION
Only ONE of the criteria below must be met.
OR
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PDS – Implementing the New PDS Policy for
Current LRI PDS Workers
Home and Community Based (HCB)
Supports for Community Living (SCL)
Current PDS employees who are
an LRI on the HCB or SCL waivers
will NOT be required to go
through this process because
they have undergone a
screening in the last several
years.
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PDS – Implementing the New PDS Policy for
Current LRI PDS Workers
Current PDS employees who are
an LRI on the ABI, ABI-LTC, or
MPW waivers will be required to
go through this process once the
waivers are effective.
Acquired Brain Injury (ABI)
Acquired Brain Injury Long-Term Care (ABI-LTC)
Michelle P. Waiver (MPW)
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PDS – Background Checks for PDS Employees
DMS revised background check requirements for PDS
employees to offer more flexibility.
PDS Employees will:
• Be able to bring previously completed background checks with them if it meets established requirements in the last 12 months.
• Must undergo a risk assessment for tuberculosis annually.
PDS Participants may waive:
• The requirement for employees to have CPR and first aid training.
• A potential PDS employee’s criminal history if it only includes lesser offenses that are not outright disqualifiers (e.g. no violent crimes or fraud).
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Case Management
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Case Management – Stakeholder Feedback
Stakeholder Feedback / Assessment Finding:
• Delays in the service authorization process
impact participant access to timely care.
• There is support to shift service authorization
to case managers provided there is training,
tools and guidance.
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Case Management – Service Authorization
Case managers will approve some services
that address participant’s needs
identified in the functional assessment.
Skilled services will be reviewed by DMS or its
designee.
All services offered under the Model II waiver are skilled
services and will need to be approved by DMS.
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Case Management – Service Authorization (continued)
• Case managers will approve:
ABI Acute
• Assessment/
Reassessment
• Companion
• Day Training
• FMS
• Goods and
Services*
• Non-Specialized
Respite
• Residential
Support Level I,
II & III
ABI LTC• Adult Day Health
• Assessment/
Reassessment
• Companion
• Day Training
• FMS
• Goods and Services*
• Natural Supports
Training
• Non-Specialized
Respite
• Residential Support
Level I, II & III
HCB• Adult Day Health
• Attendant Care
• FMS
• Goods and
Services*
• Home and
Community
Supports
• Home Delivered
Meals
• Non-Specialized
Respite
• Personal
Assistance
*DMS will approve Goods and Services requests of more than $500. 35
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Case Management – Service Authorization (continued)
• Case managers will approve:
*DMS will approve Goods and Services requests of more than $500.
MPW• Adult Day Health
• Attendant Care
• Community Living
Supports
• Day Training
• FMS
• Goods and
Services*
• Homemaking
• Non-Specialized
Respite
• Personal
Assistance
SCL• Community Access
• Community Guide
• Community Transitions
• Day Training
• FMS
• Goods and Services*
• Natural Supports Training
• Non-Medical Transportation
• Non Specialized Respite
• Personal Assistance
• Positive Behavior Planning
• Residential Support Level I & II
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Case Management – Case Management Support
Case Manager Training
Establish case management delivery expectations
Provide education to support case manager facilitation and communication to participants and their natural supports
Provide accessible training that is aligned with federal regulations and national leading practices
Include real-life scenarios to demonstrate possible issues and appropriate resolutions
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Case Management – Case Management Support
(continued)
Case Manager Help Desk
Provide timely guidance and technical assistance
Assist case managers with case specific questions
Provide policy clarification
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Case Management – Case Management Support
(continued)
Monitoring
Regularly review a random selection of participant files
Utilize standard monitoring tools to promote consistent and objective reviews
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Anticipated Implementation
Milestones and Timeline
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Implementation Milestones and Timeline
Reopen Public
Comment Waiver
Amendment (WA) #1
In-person Town Halls
Submit WA #1 to CMS
Financial Management
Agency Minimum
Standards of Practice
Released to Public
PDS Participant
Guide Released to
Public
Spring 2019
Summer 2019
Fall 2019
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Implementation Milestones and Timeline (continued)
Begin WA #2 Public
Comment
WA #1 Effective
Submit WA #2 to CMS
WA #2 Effective
Updated Waiver
Regulations Effective
Fall 2019
Winter 2020
Spring 2020
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Opportunity for Future
Stakeholder Engagement
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Opportunities for Future Stakeholder Engagement
Thank you for joining us. We appreciate your time and
attention and look forward to your continued collaboration.
Please continue to submit questions and comments to DMS
at:
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Closing and Additional
Resources
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Closing and Additional Resources
Please find additional resources regarding 1915(c) HCBS
waiver redesign on the Division for Community Alternatives
Website at:
https://chfs.ky.gov/agencies/dms/dca/Pages/default.aspx.
Additional materials include:
• Frequently Asked Questions
• The official DMS response to public comments
• HCBS – AP and Subpanel meeting minutes
• Public Announcements
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