3. Session Law 2011-264 Requires NC to implement a system for the allocation of resources (resource allocation) based on the reliable assessment of intensity of need (Supports Intensity Scale™ )

4. One key component of the NC Innovations waiver changes is the implementation of the Supports Intensity Scale ™ or SIS ™. Reliable assessment of support need for people with I/DD Looks at each person and determines what type and amount of support is needed.

6. Personal Care In Home Skill Building In Home Intensive Support Note – these three services, if currently authorized, can be continued until the end of the plan year. No new auths will be issued from 11/1/16 forward. A change from these services to the blended service can occur at any time with a revision to the ISP

8. Combines Personal Care, In-home Skill Building and In-home Intensive services Allows for habilitation, supervision and support, and will be more flexible

9. Desired Outcomes Less dependence on paid supports Learn new skills Retain existing skills Flexible – goes with the flow of daily life No wrong amount of personal care or skill building Service provided in 15 minute increments

10. Covered Tasks / Activities Supervision Assistance in completing home and community related activities Technical assistance to unpaid supports living in the home

11. Exclusions Cannot occur at the same time as other direct services Cannot provide transportation that originates from or ends at school Is not available to people in residential settings or who are receiving Supported Living

12. Limits Subject to limits on sets of services 12 hours per day is the maximum Up to 16 hours per day for exceptional circumstances with prior approval for 90 or 180 days

13. New service (formerly Community Guide) Annual informational session on self direction and self determination Agency with Choice You partner with the Provider Agency to supervise and manage workers who provide support Employer of Record Allows you or the legally responsible person to be the individual who legally can exercise authority over workers and assume the other responsibilities associated with participant direction of services.

14. Scope / Intent Promote self-determination Support in making life choices and planning for the future Help identify opportunities for community integration Less reliance on paid supports Advocacy

15. Covered Tasks / Activities Annual information sessions on self direction, rights and self determination (can opt out) Support in person centered planning processes Support in IEP, ISP or other planning processes Support in making decisions (providing education, suggesting choices, etc.)

16. Covered Tasks / Activities Advocacy Guidance in managing individual budget Assistance with issues around SSI, guardianship, DSS, financial / legal planning Help devising / negotiating roommate agreements Assistance in developing ‘life related emergency plans ’

17. Covered Tasks / Activities Assist with locating and accessing non-Medicaid supports and resources Support person to expand social relationships and build connections in the community Assist with locating options for renting / purchasing personal residence Self direction assistance for Agency with Choice and Employer of Record models

18. Exclusions Cannot duplicate Care Coordination tasks

19. Limits If provider does not provide Agency with Choice services, the only other service they may provide to the same individual is Community Transition An agency may provide both Community Navigator Services and Agency with Choice Services to the same individual in addition to Community Transition, Financial Support Services, Individual Goods and Services and Primary Crisis Response

20. This new service is a daily service, meaning that it is paid for on a daily basis (rather than hourly or 15 minute units). It’s designed for people who live in their own home. The home is not required to have a license. Up to 3 people can live in the home. One of those can be a live-in caregiver.

21. Own home is defined as a place where the person has all ownership or tenancy rights afforded under the law. There is a special needs adjustment that can be used when a person’s roommate moves out or if there is a change in support need. This provides a safety net to everyone involved.

22. Scope / Intent To support successful community living in unlicensed residences that are owned or rented by the resident(s)

23. Covered Activities / Tasks Increase or maintain life skills Provide supervision / staffing plan that ensures health and safety while increasing opportunities for self-sufficiency and self determination in the community Ensure full membership in the community Provide transportation when not reimbursed through another service or funding source.

24. Levels of Support Determined by individual budget category Level 1 – Minimal support needs; does not require overnight staff Level 2 – Moderate support needs; requires overnight staff (not required to be awake) Level 3 – Consistent onsite access to staff; staff onsite and awake overnight

25. Exclusions Must be 18 or older Not provided at same time of day as any other direct service Limits Subject to limits on sets of services Cannot be self directed Cannot be provided by a relative

27. Clarified that Community Networking can link an individual to a volunteer setting if the individual requires paid supports to participate once connected with the activity Added payment for memberships when the individual will be participating in an integrated class

28. Has limit of $5000.00 per Waiver period Allows for individuals to access Community Transition when stepping down from AFLs, PRTFs, and family homes when moving to a home of their own

29. Allows for the prevention of Crisis through Crisis Consultation Crisis Consultation includes: Facilitation of up to Monthly Team Meetings. Training and education for Natural Supports and direct supports staff. Develop and implement strategies. Allows for the prevention of Crisis through Crisis Consultation Crisis Consultation can be provided by Qualified Professionals with Crisis experience. Allows for verbal authorization followed up by a written request.

30. Primarily a Group service Emphasizes inclusion and independence Individuals 16 or older or new to the service will receive education on all types of meaningful day activities prior to starting Day Supports. Improved attendance requirement to expect individuals to physically attend the Day Supports facility only once per week unless otherwise approved by the LME-MCO, instead of requiring each day to start and end at the facility. This minimum requirement will not apply to individuals who attend Adult Basic Education classes. Improved recordkeeping accuracy by changing billing unit rate to hourly rather than 15 minutes

31. Residential Supports levels are determined by the Individual Budgeting Table Category Level 1: Individual Budgeting Categories A and B Level 2: Individual Budgeting Category C Level 3: Individual Budgeting Category D Level 4: Individual Budgeting Categories E, F, and G Staff who provide Residential Supports should not provide other waiver services to the beneficiary. Provider agency can. Clarified that Respite Services may be provided to individuals who reside in Alternative Family Living arrangements, but cannot be billed on the same day Per CMS waiver guidance, Respite care may not be furnished for the purpose of compensating relief or substitute staff for a waiver residential service. The cost of such staff are met from payments for the waiver residential service.

32. Provider Agencies - Agencies with Choice follow State Nursing Board Regulations Nursing Respite Provider - State Nursing Board Regulations must be followed Respite can be used in AFL but not on same day as Residential Supports Allows for the person receiving services to have relief at his/ her choice

33. This service may be used for evaluations for adults when the State Plan limits have been exceeded Clarification that Specialized Consultative services can be provided by “other licensed professionals” who have I/DD experience

34. Improved access to Supported Employment service by removing three-year experience requirement Provides technical support to potential employers regarding Federal ADA accommodations and requirements Added Long Term Follow-up Long Term Follow-up includes transportation when the individual’s job does not include staffing support.

35. Removed exhaustive lists to allow for flexibility as technology changes. Added broad categories Allows for the repair of equipment Allows for connectivity and smart home technology. Cost Limit: $ 50,000 over the life of the waiver (Home Modifications and Assistive Tech.) Items that are not of direct or remedial benefit to the person are excluded from this service Clarified that items used as restraints are not covered.

36. Removed Exhaustive list Cost Limit: $ 50,000 over the life of the waiver (Home Modifications and Assistive Tech.) All modifications must be of direct or remedial benefit to the individual or in some way related to the individual’s disability. This would exclude adaptations, improvements or repairs to the residence which are of general utility.

37. Allows for lifting and lowering devices Also allows for individual who owns a vehicle but lives in a residential setting to have access to vehicle modifications

38. Financial Support Services Individual Goods and Services Natural Supports and Education

40. Community Living and Support is the only waiver services that may be provided by a relative who resides in the home of the individual It is recommended that a relative provide no more 40 hours per week of service to the individual

41. Relatives can provide up to 40 hours of service without getting approval from the LME-MCO. The provider must notify the MCO when the relative is providing services for 40 hours or less The LME-MCO can approve a relative to provide up to 56 hours per week in extraordinary situations. This will be considered on a case by case basis. However 56 hours is a hard limit within the waiver – meaning that it is the absolute maximum. DMA has defined exceptional as beyond just wanting the parent as the provider. Things such as behavioral/medical issues and need for care at hours that would be difficult to staff.

42. Relatives who were providing services on 12/31/15 may exceed the 56 hour limit and be approved to provide the amount of services that they were authorized to provide as of 12/31/15 as long as the beneficiary continues to choose the relative as the staff member, there are no health and safety issues, and the individual is not isolated from their community. This does not refer to situations where the individual has left their natural home and is now residing with a relative that is not their parent/step-parent/adoptive parent. This situation may be considered an AFL.

43. Non-parents residing in the home can provide services to a minor. Clarified that parent of a minor child or the spouse may not provide waiver services to the beneficiary. A relative can provide residential supports - as long as not prohibited by relative as provider policy

44. Eliminates Relative and Direct Supports part A and part B requirements since 40 hours is allowable and rename PART C for the relatives that are providing 40 plus hours

46. One of updates in the waiver is to use Individual Budgets as a planning tool to be sure everyone gets what they need Resource Allocation project implementation is scheduled for November 1, 2016. This means all ISPs for October birthdays must include the resource allocation budget.

47. The Individual Budgeting Tool is: a system designed to standardize funding among beneficiaries who have similar support needs ensures that funding is allocated in a fair and equitable manner. All beneficiaries funded through the NC Innovations wavier are assigned to one of four categories on the Individual Budgeting Tool.

48. Beneficiaries who live in private homes can self- direct a portion of their Individual Budget or they may choose to self-direct the entire Individual Budget. Beneficiaries who live in residential programs may choose to self-direct some of the services they receive. The Individual Budget will contain both provider and individual and family directed services, depending on the needs and preferences of the participant.

49. The base budget is a guideline that does not constitute a binding limit on the amount of services that may be requested or authorized. If the LME/MCO determines services to be medically necessary, they will be authorized, regardless of the base budget. If any request for authorization of services is denied, the LME/MCO will notify the individual of the reasons for the decision and how to appeal.

50. The Resource Allocation (or Individual Budget Tool) amounts are specified on the Individual Budget Tool (IBT). The IBT contains four tables: Adult Residential/Supported Living Child Residential/Supported Living Adult Non Residential Child Non Residential For individuals that have a history of base budget expenditures significantly more or less than their IBT amount, there will be a phase in period of not to exceed three years.

51. For individuals whose base year base budget expenditures are greater than their IBT amount, the phase in percentages are established at 120%, 110%, and 100%. For example: If your base year base budget expenditures are $50,000 which is greater than the Individual Budget Tool (IBT) amount which is $40,000 the first year at 120% would be $48,000, the second year would be 110%/$44,000 and the third year at 100%would be $40,000

52. For individuals whose base year base budget expenditures are less than their IBT amount, the phase in percentages will be established at 80%, 90%, and 100% Example: If your base year base budget expenditures are $30,000 which is less than the Individual Budget Tool (IBT) amount which is $50,000 the first year at 80% would be $40,000, the second year at 90% would be$45,000 and the third year at 100%would be $50,000

53. Important Points about Individual Budgets You decide which services to request You decide how much services to request You can ask for services to be approved for up to a year You can ask for changes whenever you want

54. Important points cont. More choice More flexibility More person centered Personal responsibility Costs more predictable and sustainable No “across the board cuts”

55. Important points cont. Individual budgets are a guideline. Not a limit. If you need services that go beyond your individual budget, you can absolutely request those and they will be approved if the LME/MCO determines that they are medically necessary. There is a waiver limit, and that cannot be exceeded. That limit is $135,000. But the individual budget itself is not a limit.

56. A person’s age –whether a person is an adult or a child. Adult/Child Determination (adults are individuals greater than 22 years of age or between the ages of 18 and 22 and graduated from high school) Children have different support needs than adults, and they have different schedules. Kids are in school during the school year – much of their day has already been determined for them. The needs of children and adults are different and will be reflected in individual budgets.

57. The person’s living arrangement Services differ depending on where a person lives and the types of services they receive to live in the home. The Supports Intensity Scale, or SIS, is also used to help determine individual budgets.

58. Health and safety risks. There are supplemental questions that have been added to the SIS to identify extreme health or behavioral needs. The State looked at historical spending to help develop the individual budget model. They looked at an enormous amount of data to determine how people in NC have used services and spent service dollars. This information helps to estimate what people will need in the future.

59. Community Networking Services Day Supports Community Living and Supports Respite Supported Employment

60. Assistive Technology Equipment and Supplies Community Navigator Services Community Transition Services Crisis Services Financial Support Services Home Modifications Individual Goods and Services

61. Natural Supports Education Specialized Consultation Services Vehicle Modifications Residential Supports Supported Living

62. The changes to the Innovations Waiver will begin November 1, 2016. Personal Care, In Home Skill Building and In Home Intensive /supports have been bundled to make new service Community Living and Supports

63. Resource Allocation project implementation is scheduled for November 1, 2016. This means all ISPs for October birthdays must include the resource allocation budget. Individual budgets are a guideline. Not a limit There is a waiver limit, and that cannot be exceeded. That limit is $135,000. But the individual budget itself is not a limit.