Department of Health and Human Services Stakeholder Engagement Community Alternatives Program 1915(c) HCBS Waiver August 22, 2016 Department of Health and Human Services Stakeholder Engagement

1915(c) waiver requirements To access the waiver, the individual must: Require institutional level of care such as a nursing facility Meet the target group (population) Meet Medicaid eligibility requirements Require one or more waiver services Choose waiver services in lieu of institutional services Waiver limitations: Are supplements to state plan services (Medicaid services). May not duplicate state plan services Medically necessary services approved under Early and Periodic Screening, Diagnostic and Treatment may not be included Specifically targeted to children may not provide coverage of any service that can be offered through state plan CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

1915(c) waiver requirements Services that are diversional or recreational in nature fall outside the scope of 1915(c) Waiver funds may not be used to pay for room and board Services may not duplicate the Individuals with Disabilities Education Act or the Rehabilitation Act Waiver Entrance Criteria Do the needs clearly meet the purpose and the scope of the waiver program? Are planned services appropriate to the nature and type of need to assure health and welfare? Are selected service providers qualified to provide the service? CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

Home and Community-Based Services The cost of home and community-based services (waiver services and non-waiver services) are less than the cost of institutional services. The average per participant expenditures for waiver and non- waiver Medicaid services must not cost more than the average per person costs of furnishing institutional care. Waiver Services + Non-Waiver Services < Institutional Services Case management, respite, modifications, caregiver training, community transition, assistive technology, pediatric nurse aide, specialized medical equipment and supplies All other professional claims such as private duty nursing, home health, HIT, Hospice, durable medical equipment, and therapies (PT, OT, ST) Home and community-based services are less than or equal to institutional services Inpatient hospitalizations Nursing facility placement, both short and long term; and All professional claims while institutionalized CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

No Change CAP/C Eligibility Current Proposed Draft Target Population: 0-20 Eligibility: Medicaid Eligible children determine to be medically fragile who require… Income limit for the individual requesting waiver participation limit Assessment of Federal Poverty Limit is based on the individual’s income, not household total income Target Population: 0-20 Eligibility: Medicaid Eligible children determine to be medically fragile who require… Income limit for the individual requesting waiver participation limit Assessment of Federal Poverty Limit is based on the individual’s income, not household total income No Change CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

CAP/C Benefit Package: Family Supports Current Proposed Draft Case Management: 288 units/yr (required) Respite: up to 720 hrs/yr or 30 consecutive days institution respite based on the number of personal care hours per beneficiary Commuter Time: up to 4 hrs/day Sleep Time: 56 hrs/wk Personal Time: 20 hrs/wk Training and Education: up to $500/yr Case Management: 288 units/yr (required) Respite: 720 hrs/yr or 30 consecutive days institution respite per beneficiary (includes personal time) Commuter Time: approvable up to max. # of hour to commute to work Sleep Time: approvable up to max. # hour to support employment & inclusion Training and Education: up to $500/yr CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

CAP/C Benefit Package: Modifications Current Proposed Draft Home Modifications: up to $10,000 over the life of the waiver, prorated Vehicle Modifications: up to $15,000 over the life of the waiver, prorated Community Transition: up to $2,500 over the life of the waiver for use within initial 90-days post discharge Modification budget combined over the life of the waiver (5years) for home and vehicle modifications addition of assistive technology; no proration or annual limits Community Transition: up to $2,500 over the life of the waiver for use within initial 90-days post discharge CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

CAP/C Benefit Package: Beneficiary Care Current Proposed Draft Pediatric Nurse Aide Services: up to $75,000/yr Waiver Services: incontinence supplies, adaptive tri-cycles CAP Nursing In- Home Aide Palliative and Bereavement Counseling Care Pediatric Nurse Aide Services: based on person-centered care needs Waiver Services: reusable incontinence supplies, adaptive tri-cycles and vehicle vest Nursing available through Private Duty Nursing (state plan )* In-Home Aide available through Personal Care Services (state plan) * Palliative Care and Bereavement Counseling available through Home Health and Hospice, Behavioral Health (state plan) * and Caregiver training and education services (waiver service) * May require revision of existing state plan service definitions CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

Case Studies Under the Current Waiver Under the Proposed Draft Profile: 2 year old with congenital myopathy; vent and trach dependent; total ADLs needs; 3-4 hour suctioning; continuous pump feed at night; flaccid muscles 2 parent household; mother stays at home and father works full-time Under the Current Waiver Under the Proposed Draft Service plan Waiver services: Case management 288 units Respite 720 units Nursing 24192 units Non-waiver services: PT 4 units OT 4 units ST 4 units Service plan Waiver services: Case management 288 units Respite 2880 units Non-waiver services Nursing 24192 units PT 4 units OT 4 units PT 4 units CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

Case Studies Under the Current Waiver Under the Proposed Draft Profile: Three siblings under age 7; Child #1- fetal alcohol syndrome, seizures, developmental delays and limited to extensive assistance with ADLs; Child #2 and #3 are twins- child #2 mitochondrial metabolism disorder; child #3 mitochondrial metabolism disorder, G-Tube and grand-mal seizures; both requires 2-4 hours of supervision and intervention Father has custody and works full-time Under the Current Waiver Under the Proposed Draft Child #1 Wavier services: In-home Aide 10644 units CM 288 units Respite 240 units Child #2 &3 Waiver services: CAP nursing 23296 units CM 288 units Respite 240 units Child #1 Waiver services: CM 288 units Respite 2880 units (shared) Non-waiver In-home aide 10644 units Child #2 & 3 Waiver services: CM 288 units Respite 2880 units (shared) Non-waiver Nursing 23296 units CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

Case Studies Under the Current Waiver Under the Proposed Draft Profile: 10 year old; Cerebral Palsy; Asthma; total dependence on all ADLs; PRN medication to include O2 Custody granted to grandparents; grandmother stays at home; grandfather works full-time Under the Current Waiver Under the Proposed Draft Service plan Waiver services: Pediatric nurse aide 4160 units Respite 2880 units Case management 288 units Home modification $10,000 Service plan Waiver services: Pediatric nurse aide 4160 units Respite 2880 units Case management 288 units Home modification $10,000 CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

Case Studies Under the Current Waiver Under the Proposed Draft Profile: 5 year old; premature at birth; delayed motor skills; left-side weakness; low weight; G-J tube feedings; extensive assistances with ADLs Two parent household; both parents work full-time Under the Current Waiver Under the Proposed Draft Service plan Waiver services: Case management 288 units Respite 1440 units PNA 13728 units Non-waiver services: PT 4 units ST 4 units Service plan Waiver services: Case management 288 units Respite 2880 units PNA 13728 units Non-waiver services: PT 4 units ST 4 units CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

Case Studies Under the Current Waiver Under the Proposed Draft Profile: 13-year-old with spina bifida, hydrocephalus, limited to extensive needs for ADLs, 2 parent household; Mom works part-time, Dad full time Under the Current Waiver Under the Proposed Draft Service plan Waiver services: Case management 288 units Respite 1440 units In-home aide 13,104 units Service plan Waiver services: Case management 288 units Respite 2880 units Non-waiver services: In-home aide 13,104 units CAP/C 1915(c) HCBS Waiver Stakeholder Engagement