1. MINNESOTA DEPARTMENT OF HUMAN SERVICES Disability Services Division Disability Home and Community Based Waivers 101 Odyssey Conference June 2013

2. Presenters Shannon Smith, DHS, Disability Services Division, Regional Resource Specialist (RRS) Christina Samion, DHS Disability Services Division, Disability Waiver Policy

3. Background  Medical Assistance program began – 1965 as a cooperative venture jointly funded by the federal and state governments  MA’s main purpose was to cover primary and acute health care services  Long Term Care was limited to skilled nursing facility services for person’s over 21

4. State’s Responsibilities To participate in MA states must:  Establish eligibility standards  Determine the type, amount, duration, and scope of services  Set rates of payment for services  Administer the programs  Must submit state plan to the federal government for approval

5. Home and Community-Based Waivers  1981 Social Security Act was amended establishing the 1915 (c)  Home and community-based service (HCBS) waivers  Medicaid ( MA) funding could be used to cover a variety of home and community- based services as an alternative to institutionalization

6. The Amendments or Waivers to the Social Security Act Created the home and community-based services (HCBS), which encouraged states to develop programs to prevent institutionalization and increase consumers’ community integration.

7. The Amendments or Waivers to the Social Security Act According to the Centers for Medicare Medicaid ( CMS) Forty-eight States and the District of Columbia offer services through HCBS waivers.

8. Institutions Intermediate Care Facility for Persons with Developmental Disabilities (ICF/DD) Hospital Neurobehavioral hospital Nursing facility

9. HCBS Waivers and AC Enacted into State Law  1981 Alternative Care (AC)  1982 Elderly Waiver (EW)  1984 Developmental Disability (DD)  1985 Community Alternative Care (CAC)  1987 Community Alternatives for Disabled Individuals (CADI)  1992 Traumatic Brain Injury (TBI)  NF - Nursing facility  NB - Neurobehavioral (1994)

10. The Americans With Disabilities Act The Americans with Disabilities (ADA) Act of 1990 guarantees equal opportunity for persons with disabilities in public accommodations, employment, services and telecommunications.

11. The Olmstead v. L.C. Decision The Olmstead Supreme Court decision of 1999 supported the ADA Title II standard that makes it a legal right to be served in the most integrated setting.

12. Federal Assurances of HCBS Waiver  HCBS Waivers are not an entitlement  Person chooses to reside in the community  Community support plan assures health and safety of the person  Services are necessary to avoid institutionalization

13. Federal Assurances of HCBS Waiver  Person needs services that are not available under MA State Plan or exceed amount, scope and duration of services available under MA State Plan  Services are cost effective  Service authorization is based on individual need and addressed in the person’s community support plan

14.  Level of care need is consistent with need for institutionalization  State Medicaid agency retains administrative authority over waivers  State provides financial accountability for waivers Federal Assurances of HCBS Waiver

15.  County Lead agency, managed care organizations and tribal human service agencies administer programs at the local level  Counties work in partnership with DHS and other organizations to provide information, services and assistance to people with disabilities

16. Federal Assurances of HCBS Waiver  Qualified providers serve participants  Consumer access – participants are informed about available services and options  Consumer safeguards - participants can exercise rights and responsibilities

17. Eligibility Criteria for the Disability Waivers Eligible for Medical Assistance Need the Level of Care Informed about choices Certified disabled for the CAC, CADI, and BI Waivers

18. Eligibility Criteria for the Disability Waivers  Under the age of 65 years at time of opening to the waiver for CAC, CADI and BI  Has an assessed need for supports and services  BI: The person had a diagnosis that substantiates a traumatic brain injury

19. Developmental Disabilities Waiver  Has a DD diagnosis or related condition  Needs daily interventions, daily service and a 24 hour plan of care  Cannot apply skills learned in one environment to a new environment without aggressive and consistent training

20. Nursing Facility Level of Care  Unstable health  Need for complex care management  Functional limitation  Existence of complicating conditions  Cognitive or behavioral condition  Frailty or vulnerability

21. Hospital Level of Care 1. Need for skilled assessment and intervention multiple times during a 24- hour period 2. Due to their health condition, has both predictable health needs and the potential for status changes that could lead to rapid deterioration or life- threatening episodes

22. Hospital Level of Care 3. Require a 24-hour plan of care, that includes a back-up plan, to reasonably assure health and safety in the community 4. Without the provision of services under the CAC Waiver, would require frequent or continuous care in a hospital

23. Neurobehavioral Hospital Level of Care 1. Require specialized brain injury services and/or supports that exceed services available in BIW-NF 2. Require a level of care and behavioral support provided in a neurobehavioral hospital to support persons with significant cognitive and severe behavioral needs

24. Neurobehavioral Hospital Level of Care 3. Require a 24 - hour plan of care that includes a formal behavioral support plan and emergency back-up plan to reasonable assure health and safety in the community 4. Require availability of intensive behavioral intervention

25. Level of Care  Hospital level of care as defined in Code of Federal Regulations 42, Section 440.10Section 440.10  Nursing facility level of care as defined in Sec. 1919 of the Social Security ActSec. 1919  ICF/DD level of care as defined in Code of Federal Regulations 42, Section 440.150Section 440.150  Waiver requirements for level of care: Code of Federal Regulations 42, Section 441.301Section 441.301

26. Developmental Disability Services  24-Hour Emergency Assistance  Adult Day Care/Adult Day Care Bath  Assistive Technology  Caregiver Training and Education  Case Management  Chore Service  Consumer Directed Community Supports (CDCS)  Consumer Training &Education  Day Training and Habilitation  Environmental Accessibility and Adaptations  Home Delivered Meals  Homemaker  Housing Access Coordination  Live-In Personal Caregiver Expenses  Personal Care Assistance Extended  Personal Support  Residential Habilitation (In- Home Family Support, Supported Living Services)  Respite & Crisis Respite  Specialist Services  Supported Employment Services  Transportation  Transitional Services

27. CAC Services  Case management/ case aide  Consumer-directed community supports (CDCS)  Environmental / Accessibility Adaptations  Extended Home Care Services  Family Training and counseling  Foster care  Home Delivered Meals  Homemaker  Respite  Specialized Supplies and Equipment  Transportation  Transitional Services  Adult Day Care- FADS

28. CADI Services  Adult Day Care/Adult Day Care Bath  Adult Companion Service  Behavioral Support  Caregiver Living Expenses  Customized Living  Customized Living 24 Hour  Case Management/ case aide  Consumer-Directed Community Supports (CDCS)  Chore Services  Environmental Accessibility/ Adaptations  Extended Home Care Services  Family Training and counseling  Foster Care  Home delivered meals  Homemaker  Housing Access Coordination  Independent Living Skills (ILS) Training  Prevocational services  Residential care services  Respite care  Specialized supplies & equipment  Supported employment  Transportation  Transitional services  24-Hour Emergency Assistance

29. BI Services  24-Hour Emergency Assistance  Adult Companion Services  Adult Day Care/Adult Day Care Bath  Behavioral Support  Case Management  Case Management Aide  Chore Services  Consumer Directed Community Supports (CDCS)  Customized Living  Customized Living 24 Hour  Environmental Accessibility/ Adaptations  Extended Home Care Services  Family Training and Counseling  Foster Care  Home Delivered Meals  Homemaker

30. BI Services Continued  Housing Access Coordination  Independent Living Skills (ILS) Training  ILS Therapies  Night Supervision Services  Prevocational Services  Residential Care Services  Respite  Specialized Supplies and Equipment  Structured Day Program  Supported Employment Services  Transitional Services  Transportation

31. CAC Waiver- Historical Summary SFY07-12 Fiscal YearPersons ServedAverage Monthly Payment Total Payments 2007241$4,686$13,556,616 2008279$5,106$17,064,201 2009300$5,364$19,303,360 2010312$5,100$19,115,670 2011314$5,277$19,887,960 2012328$5,628$22,139,579

32. CAC Waiver- SFY13-17 Forecast Fiscal YearPersons Served Average Monthly Payment Total Payments 2013341$5,703$23,351,861 2014356$5,740$24,539,367 2015370$5,832$25,886,289 2016383$5,869$26,969,940 2017396$5,905$28,055,065 Trends in the CAC Forecast: Costs do not include homecare and state plan services. Data compiled 12/19/12

33. CADI Waiver- Historical Summary SFY07-12 Fiscal YearPersons ServedAverage Monthly Payment Total Payments 200710,104$1,843$223,404,268 200811,763$2,070$292,163,020 200913,320$2,294$366,627,944 201014,226$2,416$412,365,390 201115,692$2,517$474,008,596 201216,483$2,548$504,023,987

34. CADI Waiver- SFY13-17 Forecast Fiscal YearPersons Served Average Monthly Payment Total Payments 201317,307$2,670$554,411,927 201418,239$2,793$611,388,226 201518,843$2,970$671,642,626 201620,726$3,115$774,871,255 201722,755$3,258$889,601,089 Trends in the CADI Waiver Forecast: Costs do not include homecare and state plan services. Data compiled 12/19/12

35. BI Waiver- Historical Summary SFY07-12 Fiscal YearPersons ServedAverage Monthly Payment Total Payments 20071,245$5,286$78,936,988 20081,315$5,588$88,152,050 20091,357$5,883$95,819,057 20101,359$5,912$96,378,382 20111,348$5,970$96,593,317 20121,342$5,989$96,475,267

36. BI Waiver- SFY13-17 Forecast Fiscal YearPersons Served Average Monthly Payment Total Payments 20131,370$6,054$99,505,198 20141,414$6,222$105,599,737 20151,459$6,482$113,462,340 20161,503$6,689$120,672,803 20171,548$6,899$128,137,244 Trends in the BI Waiver Forecast: Costs do not include homecare and state plan services. Data compiled 12/19/12

37. DD Waiver- Historical Summary SFY07-12 Fiscal YearPersons ServedAverage Monthly Payment Total Payments 200714,103$5,325$901,129,015 200813,971$5,537$928,369,470 200914,176$5,673$965,104,543 201014,647$5,597$983,708,433 201115,165$5,596$1,018,441,737 201215,449$5,569$1,032,442,037

38. DD Waiver- SFY13-17 Forecast Fiscal YearPersons Served Average Monthly Payment Total Payments 201315,735$5,734$1,082,726,395 201416,068$5,846$1,127,074,542 201516,449$6,014$1,186,977,268 201616,895$6,139$1,244,497,600 201717,396$6,263$1,307,461,975 Trends in the DD Waiver Forecast: Costs do not include homecare and state plan services. Data compiled 12/19/12

39. Trends in the CCB & DD Waiver Forecast: Enrollment limits Foster Care Moratorium Waiver Waitlist

40. Waiver Service Planning 1. Use person centered planning to discover the person’s needs and desires. 2. Individualize services based on person’s needs and desires. 3. Focus on quality of life and accommodate preferences as much as possible.

41. Waiver Service Planning 4. Work with the person to determine acceptable options. 5. Regularly assess and monitor services. 6. Change services or supports if person is dissatisfied.

42. Consumer Directed Community Supports (CDCS)  Service option available under the CAC, CADI, DD and BI Waivers  Gives the persons more flexibility and responsibility for directing their services and supports

43. CDCS Eligibility  Receiving services on a MA waiver in Minnesota  Meet all eligibility criteria for a MA waiver  Authorized to receive waiver services by the county

44. CDCS Persons not Eligible  CDCS recipients who have exited the waiver more than once during their service plan year  Persons who have had their eligibility restricted at any time by the MN Restricted Recipient Program ( MRRP)  Waiver recipients living in residential settings licensed by the Department of Human Services (DHS) or licensed/registered with the Minnesota Department of Health (MDH)

45. Federal Assurances of CDCS Budgets  CDCS Lead Agency Operations Manual (DHS-4270) CDCS Lead Agency Operations Manual (DHS-4270)

46. QUESTIONS??

47. Disability Services Division Main Phone Numbers 1 (651) 431 - 4300 or 1 (866) 267-7655 Email Address: DSD.ResponseCenter@state.mn.us