Impact of CMS Final Rule on Home & Community-Based Services Ask participants if they are familiar with Medicaid Waivers Any current waiver participants? November 30, 2016

History of the Rule The settings rule was effective March 17, 2014. For settings not in compliance with HCBS standards, states have until March 2019 to bring their waiver programs into compliance. Rule has been in the works for several years. CMS solicited and responded to over 2,000 public comments.

What is “Home and Community-Based”? The rule emphasizes personal autonomy, choice, and community integration. The focus is on the nature of people’s experiences. Supports states’ efforts to comply with requirements of Olmstead. The rule is really about a culture change – not just an making some environmental changes. Assisted Living is NOT “nursing home lite” under this rule. Person-centeredness is going to be the key to getting this right.

Requirements for ALL HCB Settings The setting is integrated in and supports full access to the greater community; The setting is selected by the individual from among setting options; Each individual has a right to privacy, is treated with dignity and respect, and is free from coercion and restraint; Provides individuals independence in making life choices; The individual is given choice regarding services and who provides them.

Settings Presumed Institutional Settings in the same building as a NF; Settings adjacent to a public institution; Settings that isolate Medicaid participants from the larger community of non-Medicaid participants. These settings are subject to “heightened scrutiny” by the states and CMS to ensure meet HCBS characteristics. In CMS’ experience, most Continuing Care Retirement Communities (CCRCs), which are designed to allow aging couples with different levels of need to remain together or close by, do not raise the same concerns around isolation as the examples above, particularly since CCRCs typically include residents who live independently in addition to those who receive HCBS. Ability to interact standard is the same for non participants and participants – so a rural setting should be similar to what other people living in those areas would experience in terms of integrate but people should not be “shipped off” to rural settings A state may only include such a setting in its Medicaid HCBS programs if CMS determines through a heightened scrutiny process, based on information presented by the state and input from the public that the state has demonstrated that the setting meets the qualities for being home and community-based and does not have the qualities of an institution.

Required Characteristics The individual has a lease or other legally enforceable agreement providing similar protections; Each individual must have privacy in their living unit including lockable doors; The individual has the option of a private room; Individuals sharing a living unit must have choice of roommates; Individuals must be allowed to furnish or decorate their own sleeping and living areas; The individual controls his/her own schedule including access to food at any time; The individual can have visitors at any time; and The setting is physically accessible. People should be able to lock their doors, but facility/state can put limitations on what kinds of locks can be used (e.g. chain locks, or dead bolts). Access to food doesn’t have to mean full meals 24 hours a day, but people should be able to access a simple snack, like an apple, if they miss a meal or choose not to eat at pre-determined time. (access to food in personal apartments is okay here for AL) Shower times/assigned seating…..

Indiana’s Assessment Process Self assessment in 2014 More robust systemic assessment in 2015 Site visits to all waiver providers in 2016 and continued review of systemic elements About 2000 participants in Medicaid AL

Assessment Findings About 60% of current providers meet presumed institutional characteristics. Significant challenges with the residential care licensing rules. Need for operational and policy changes to comply with the CMS rule.

Transition Plan Working with ISDH to craft “waivers” that facilitate continued operation of current program. Formed workgroup to incorporate CMS requirements into rules for participation in Indiana Medicaid AL. Plan new Medicaid certification, not based on RCF licensure. Establishing new waiver (or state plan option) that permits expansion of Medicaid AL.

Housing with Services? Emphasis on housing first. How to balance resident choice and autonomy with perceived provider liability. Facilitating aging in place if/when acuity of care needs increases. Dementia focused services

What are “Services”? Look at current service definitions How are services delivered in unlicensed environments? How to preserve resident choice while optimizing use of most cost effective provider? What happens when the resident may not be safe in that setting any longer?

Person Centered Planning On an individualized basis, the required characteristics can be modified, if the resident’s personal circumstances warrant. Collaboration between resident, their family, provider, and case manager. Must be able to demonstrate failure of previous interventions to alleviate areas of concern.

Heightened Scrutiny Letters will go out early 2017. Closing the “front door” to presumed institutional providers at this time. If provider believes they can remediate and/or overcome the presumption: Remediation plan Required documentation Public comment CMS Review

Timeline Now-February 2017: Current hiatus on new providers while new standards are written. 1st Quarter 2017: Letters to current providers with assessment findings and remediation requirements. Closing “front door” on providers who choose not to remediate and presumed institutional providers.

Timeline (cont) 2nd Quarter 2017: Start new rule promulgation process with updated HCBS provider requirements. Also – turn workgroup focus to development of new AL/HCBS program. Goal is new program in place July 1, 2018. 3rd Quarter 2018: Transition providers/residents to new program.

Additional Information Indiana’s HCBS Final Rule Website: http://www.in.gov/fssa/4917.htm CMS HCBS Website: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Home-and-Community-Based-Services/Home-and-Community-Based-Services.html