The Medicaid waiver program Jetta Whittaker Senior and Disabilities Services

What is the MEDICAID WAIVER program? Authorized by sec. 1915(c) of Social Security Act Administered by the Centers for Medicare and Medicaid (CMS) Funded in partnership with Feds according to a factor known as the FMAP – 50/50 Allows states to “waive” certain Medicaid rules to target certain populations

What is the MEDICAID WAIVER program? Vehicle for funding home and community-based services (HCBS) Alternative to institutional care One of an expanding number of options for providing HCBS 1915(i) – State Plan HCBS 1915(j) – “Cash and Counseling” 1915(k) – “Community Choice Option,” comes with 6% FMAP incentive

Who is served by the MEDICAID WAIVER program in alaska? People with intellectual and developmental disabilities (IDD Waiver) Adults age 65+ and those with physical disabilities (ALI Waiver) Children with complex medical needs (CCMC Waiver) People with intellectual and developmental disabilities (APDD)

Eligibility for the MEDICAID WAIVER program Financial eligibility for Medicaid Functional assessment – standardized tool, criteria Decision by the state that your functional capacity is such that you need the “level of care” available in an institution, e.g., nursing home, ICF/IDD

What services are available on the medicaid waiver program? Full array of long-term services and supports Care coordination Personal care/chore Residential care Habilitation/Intensive active treatment Primary provider respite Supported employment Transportation Meals Environmental modifications

Who provides the HCBS? Private, for- and non-profit, community-based agencies Assisted living homes All sizes, experience Over 400 different agencies statewide Can provide care coordination and services

Who oversees? SDS provides assurances to CMS that these services will be “quality” services and that recipients who receive them will be safe in their homes and communities Promulgation of regulations SDS “certification” of each services they provide Adherence to Conditions of Participation Oversight and monitoring, corrective action Decertification

Overview - Changes to federal 1915(c) waiver regulations Emphasis not just on quality services, but on quality of life for recipients of waiver services; CMS-defined “home and community-based settings in which services may be provided;” “Conflict-free” care coordination Added protections for recipients in provider-controlled or operated residential settings

Two major areas of Change Person-Centered Planning Separation of service planning and service provision; New requirements for documentation of options offered to the recipient; Real choice for recipient free from pressure and undue influence

Two major areas of Change Home and Community-Based Settings Requires the state to verify that all recipients of Medicaid home and community-based waiver services receive those services in integrated community settings, selected by the recipient from among setting options, including non-disability specific settings, appropriate to their needs, and that those settings provide “full access” to the benefits of community living.

Home and Community-Based Settings The federal Center for Medicare and Medicaid (CMS) has clarified that “full access to the benefits of community living” means:  “the same degree of access as individuals not receiving home and community-based services, including opportunities to: seek employment and work in competitive, integrated settings; engage in community life; control personal resources; receive services in the community”

Home and Community-Based Settings CMS-defined qualities of a “home and community-based setting: Physically accessible; Choice of roommates; Freedom to furnish and decorate; Freedom and support to control schedules and activities; Access to food (snacks) at any time; Visitors at any time

Home and Community-Based Settings CMS-defined qualities of a “home and community-based setting: In a provider-owned or controlled residential setting the following additional conditions must be met: Must be rented or occupied under a “legally enforceable” agreement such as a lease or rental agreement; Have the same responsibilities and protections from eviction that tenants have under the landlord/tenant law of the state; Privacy in sleeping or living unit; Entrance doors lockable by the individual with only appropriate staff having keys to doors.

Home and Community-Based Settings Settings that can never be home and community-based: Nursing facility; Institution for mental disease; ICF/IDD; Hospital; Any setting co-located with, on the grounds of, or immediately adjacent to a public inpatient institution Any other location that has the effect of isolating individuals from the broader community.

Person-Centered Planning “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, except when 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.” 42 CFR 441.301(c)(1)(vi)

Person-Centered Planning “Conflict-free” case management that provides complete separation of service planning activities and service provision. Prohibition on any agency providing both case management and home and community-based services; CMS clarification: there is no acceptable degree or percentage of financial or organizational affiliation between agencies that will allow provision of care coordination and service provision.” Only exception: when only one qualified and certified agency in a geographic area is available and willing to provide both

Person-Centered Planning Regulations are forcing significant changes in Alaska’s HCBS system SDS engaged in planning process with providers Conflict free at the individual or agency level? The practical issues around separating service planning from service provision Regulations must be in place by July 1, 2016

MEDICAID WAIVER PROGRAM/ CMS REGS QUESTIONS? Jetta Whittaker, Manager, Policy and Program Planning jetta.whittaker@alaska.gov